Nevada hospital engagement network -...

Nevada Hospital Engagement Network Monthly Report

September 9, 2013

Centers for Medicare & Medicaid Services Partnership for Patients Initiative

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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

Cost Savings and Patient Lives – Table 2 ................................................................................................................... 5

Adverse Drug Events (ADE) ..................................................................................................................................... 6-11

Catheter Associated Urinary Tract Infections (CAUTI) ............................................................................... 12-16

Central Line Associated Bloodstream Infections (CLABSI) ....................................................................... 17-20

Early Elective Delivery (EED) ................................................................................................................................ 21-22

Falls with Significant Injury ................................................................................................................................... 23-26

Obstetrical Adverse Events (OB).......................................................................................................................... 27-30

Pressure Ulcers ........................................................................................................................................................... 31-33

Readmissions ............................................................................................................................................................... 34-38

Surgical Site Infections (SSI) .................................................................................................................................. 39-42

Ventilator-Associated Pneumonia/Event (VAP/VAE) ................................................................................. 43-46

Venous Thrombo Embolism (VTE) ..................................................................................................................... 47-49

Patient and Family Engagement ........................................................................................................................... 50-52

Leadership Engagement .......................................................................................................................................... 53-54

Forward Look for the Next 30 Days ........................................................................................................................... 55

Partnerships and Collaboratives ................................................................................................................................. 56

Financials and Attachments .......................................................................................................................................... 57

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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 was 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, 60% or greater of the PfP-eligible facilities participated in providing data in all 10 HACs and readmissions (Figure 1). PfP-eligible facilities within the NV HEN are showing greater than 40% reduction in 4 HACs and greater than 17.6% in 2 HACs (Figure 2).

Figure 1: Participation rate of PfP eligible facilities per HAC plus readmission. Red solid line indicates the 60% participation threshold defined by CMMI.

Figure 2: % improvement in each HAC and readmission rate for PfP eligible facilities. Dashed blue line indicates the 17.6% reduction threshold and the solid blue line indicates the 40% reduction threshold.

(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)

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

Hospital Acquired Conditions (HACs) and Readmissions for PfP-eligible facilities. • IMPROVEMENT RATES: Four HACs are showing overall improvement rates of 30% or greater

within the group of HACs that had 60% or greater reporting level (PfP-eligible facilities). Two other HACs have improved more than 17.6% but not yet achieved 30% reduction (PfP-eligible).

• SITE VISITS: 15 facilities site visits including 4 rural facilities who, as a group, have been challenging to engage.

• HARM REDUCTION IMPACT: We estimate that the reductions in harm achieved by our facilities will save 1,680 patients from harm and more than $18 million annually (Table 2)

• PATIENT-FAMILY ENGAGEMENT (PFE), ADVERSE DRUG EVENTS (ADE) and READMISSIONS PROGRESS: We are collaborating with the NV QIO to co-sponsor a “Brown Bag” event in Henderson, Nevada (adjacent to Las Vegas). 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 through their Care Transitions work. They will also display informational posters and provide take-away education materials and pillboxes. The HEN is sponsoring the speakers (Touro University Falls Assessment Team; Rest of Your Life Planning) who will talk throughout the day and interact 1:1 with attendees. We will also be providing a list of local physicians who are taking new patients (and their insurance plans). The event is targeted for early November.

• INFORMATION TECHNOLOGY: New phase of our plan is to leverage information technology to support the PfP’s goals. We entered a new partnership with HealtHIE Nevada to maximize the data potential of the Health Information Exchange. Although this is a long-range plan, we will continue through year 3 of the HEN contract to lay the infrastructure for ongoing development. To be consistent with recent CMS feedback on meaningful use and patient access to records, we will likely be working with them to prioritize laboratory data access for patients and caregivers. This has some challenges due to the variety of lab systems that may have varying test content and definition. In order for the information to be accessible and meaningful to patients and caregivers, there will need to be some standardization in the industry.

• MONTHLY HEN CALL – The focus for our August call was A Call to Action on the rising trends of CAUTI and CLABSI. We used the Signature Style method to motivate the facilities to the call to action. 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 in tools. Then we REQUESTED our attendees to COMMIT to actions (verify bundle compliance, spread CUSP CLABSI to other units, verify sterilization techniques, etc.). The NV HEN will follow up with the facilities individually, through our newsletter, and at our next monthly call for NV HEN members to look for action on their commitment.

• ADE – We have maintained the 60% participation rate! We attribute this success to offering more measurement options to our facilities and continuing to develop 1:1 relationships with pharmacy leads. During recent national PfP events (August 5th and August 20th), the NV HEN shared our successful strategies and two of our facilities were invited to share their best practices. For more information see the “Adverse Drug Events” section of this report.

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

aggregate improvement is only 6%. For more details, see the ADE section of this report. • CENTRAL LINE ASSOCIATED BLOOD-STREAM INFECTIONS (CLABSI) is still showing

improvement from baseline, but compared to the previous quarter, the rate has increased. We polled our facilities to gain a better understanding of these results and targeted this topic by initiating a Call to Action (see details in CLABSI section). In addition, we will leverage our Level 5 (Hospital 2 & 8) hospitals’ strategies with their peers to help move them to improve beyond their current rate.

• CATHETER ASSOCIATED URINARY TRACT INFECTIONS (CAUTI) is showing an overall rising trend (3%). Similar to CLABSI, we have asked for commitments from our facilities to review their bundles and determine whether staff is compliant with these bundles. This Call to Action was presented during our NV HEN monthly call, at the 5th Friday of the Month Nevada Hospital Association convening of Nurse and Quality Leaders and will emphasize this commitment during our “Taking Stock”.

• PRESSURE ULCERS (STAGES III AND IV) remains a challenge. We have northern and southern advisory committees that have been working on strategies, spreading best practices and discussing new technologies. In the southern Nevada PU advisory committee, the NV HEN spread knowledge about the Medline NE1 evaluation method and tool. From the northern Nevada PU advisory committee we received updates from KCI in regard to current wound treatment and prevention. We are educating our facilities on current best practice and encouraging promotion of prescribed and mandatory PU prevention measures. For more details, see the Pressure Ulcer section of this report.

• READMISSION NV HEN aggregate data is showing 6% improvement, but remains below target. The August Medicare fee for service national data shows more than 7% improvement in Nevada and our state is tied for the number 3 spot for improvement in readmission rates for the Medicare population. We are partnering with our QIO to advance strategies across the continuum of care. For more information, see Readmission section of this report.

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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)

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COST SAVINGS AND PATIENT LIVES

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 (ADE)

TABLE 3: SUMMARY OF ADVERSE DRUG EVENTS RATES

Adverse Drug Events

Participating Hospitals

% Participating Baseline Current

%

Decrease

PfP-Eligible Hospitals 15 / 25 60%

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

19.9 20.2 -2%

Period Jan-March 2012

March-May 2013

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

0.024 0.029 -21%

Period Jan-June 2012

April-June 2013

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

5.5 5.1 8%


March-May 2013

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

97%

Overall ADE Rate 6%

Notes: Combined rate is the weighted average of 4 outcome measures. Negative values indicate increase in ADE rate.

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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 (as defined by the facility) 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 from some of our facilities since 2010, our 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 improvement for ADEs for PfP eligible facilities by taking a weighted average of the percent change from the 3 outcome measures and the 1 facility self-reporting a Medication Error rate (Table 1) to obtain an overall improvement rate of 6%.

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 2% from a baseline rate of 19.9 to a rate of 20.2. The red line is a linear trend line that is fit to the baseline insulin rate and current insulin rate.

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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 21% from a baseline rate of 0.024 to a rate of 0.029. The red line is a linear trend line that is fit to the baseline anticoagulant rate and current anticoagulant rate.

Figure 5: Rate per 1,000 narcotic doses administered for PfP eligible facilities. In current reporting period, the narcotics rate decreased 8% from a baseline rate of 5.5 to a rate of 5.1. The red line is a linear trend line that is fit to the baseline narcotics rate and current narcotics rate. (Baseline=13 facilities; Current=13 facilities)

NOTES:

• 2 PfP eligible facilities are reporting alternative metrics for ADE Insulin (# below range blood glucose (BG)/# of BG Readings) and ADE AntiCoagulants (# out of INR/# of INR Readings). These facilities have not yet supplied enough historical data to establish a trend.

• One PfP eligible facility reports on ADEs using the metric they use internally. Their data shows a 97% decrease in Medication Errors in the first 4 months of 2013 against a 2011 benchmark.

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DATA ANALYSIS AND RESULTS FOR NON PFP-ELIGIBLE FACILTIES: One non-PfP eligible facility reported on all 3 ADE outcome measures and no ADEs related to Narcotics during the past 8 months. Another non-PfP facility reports all ADEs over Medication Doses dispensed which shows 60% improvement 2013 (1st 4 months) vs. 2010 baseline. Three non-PfP facilities report ADEs per 1,000 patient days which have decreased 35% comparing 2012 and 2013 (4 months)

HARM AVOIDED AND PROJECTED COST SAVINGS: Assuming an average of $5850* saved per Narcotic related adverse event, we estimate that our self-reporting PfP-eligible facilities saved 70 patients from harm and had a cost savings of $409,990 in the current time period (Table 2). We further estimate an annual cost savings of $1,639,960 and 280 patients saved for narcotics alone.

* Bates DW, Spell N, Cullen DJ, Burdick E, Laird N, Petersen LA, Small SD, Sweitzer BJ, Leape LL (1997)“The costs of adverse drug events in hospitalized patients. Adverse Drug Events Prevention Study Group”. JAMA.; 277(4):307-11.

STRATEGIES AND SUCCESSES TO DATE: • North Vista hospital’s assistant director of pharmacy, J.C. Schneider, participated in the August 5th

national call on 5-day Post Discharge Med Reconciliation. He shared their best practice of distributing a wallet card to every patient upon discharge, which itemizes their most current medication profile and vaccination status. They are seeing some success as patients return for other services with an updated card in hand. Marissa Brown represented the NV HEN and shared some of the strategies we are using to operationalize and standardizing med rec programs in our facilities.

• August 20, Evelyn Chu, director of pharmacy for Desert Springs Hospital (Valley Hospital System) participated in the medication safety affinity group call. She shared how they are handling the metric/data requirements for the three ADE topics: Insulin, Anticoagulants and Narcotics.

• Three facilities have reached level 4 status; 5 facilities have reached level 3 • Currently 60% of our PfP eligible network is providing data, so the NV HEN has met the

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

• Five NV HEN hospitals have removed Codeine from their approved Pediatric use formulary in response to a new FDA warning: http://www.fda.gov/Drugs/DrugSafety/ucm313631.htm

• Hospital Y has placed Pharmacists in their Emergency and Oncology departments and is seeing positive results in ADE detection and prevention.

• Emphasis on a multi-pronged approach (correction of standardized, written and electronic order sets; removal of faulty blood collection tubes; increasing pharmacist order review and anticoagulation clinic referrals and the use of some newer pharmaceutical agents to replace Warfarin) with anticoagulants has shown to be effective in turning around a negative trend.

http://www.ncbi.nlm.nih.gov/pubmed?term=Bates%20DW%5BAuthor%5D&cauthor=true&cauthor_uid=9002493

http://www.ncbi.nlm.nih.gov/pubmed?term=Spell%20N%5BAuthor%5D&cauthor=true&cauthor_uid=9002493

http://www.ncbi.nlm.nih.gov/pubmed?term=Cullen%20DJ%5BAuthor%5D&cauthor=true&cauthor_uid=9002493

http://www.ncbi.nlm.nih.gov/pubmed?term=Burdick%20E%5BAuthor%5D&cauthor=true&cauthor_uid=9002493

http://www.ncbi.nlm.nih.gov/pubmed?term=Laird%20N%5BAuthor%5D&cauthor=true&cauthor_uid=9002493

http://www.ncbi.nlm.nih.gov/pubmed?term=Petersen%20LA%5BAuthor%5D&cauthor=true&cauthor_uid=9002493

http://www.ncbi.nlm.nih.gov/pubmed?term=Small%20SD%5BAuthor%5D&cauthor=true&cauthor_uid=9002493

http://www.ncbi.nlm.nih.gov/pubmed?term=Sweitzer%20BJ%5BAuthor%5D&cauthor=true&cauthor_uid=9002493

http://www.ncbi.nlm.nih.gov/pubmed?term=Leape%20LL%5BAuthor%5D&cauthor=true&cauthor_uid=9002493

http://www.ncbi.nlm.nih.gov/pubmed/9002493

http://www.fda.gov/Drugs/DrugSafety/ucm313631.htm

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OPPORTUNITIES FOR IMPROVEMENT: • Insulin had historically been showing a positive trend, but has recently shown a 2% increase over

baseline (11 unique facilities reporting this period). This may be attributed to the conversion of many of the hospitals to EndoTool or other similar technology that has been implemented in the ICUs and ORs to ensure very tight control of those patients’ blood sugars. With the EndoTool, monitoring is more frequent (usually hourly) for 1 or 2 days at a minimum. If this repeat testing is detecting low blood sugars, insulin would not be dosed (denominator), but the low blood sugar would be reportable (numerator) – thus increasing the overall ratio. If this is the case, the problem should begin to normalize over time.

o Warfarin (INR) data is showing a 21% increase from baseline with 12 unique facilities reporting current data within the past rolling 3 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).

o The Nevada HEN ADE Advisory Committee participation has diminished – we are reaching out to leadership to stimulate meaningful participation and attendance.

o We are working with the Nevada Rural Healthcare Partners (NRHP) to analyze aggregate data from several CAHs so that the outcomes are actionable and meaningful. We are helping them develop a commitment and a methodology to move in that direction. Rural and CAH hospitals will be reporting different metrics on ADE into a central

point so that the HEN receives the data from one point person who will collect and report on their behalf. Their metrics will include the number of sentinel event ADEs reported (this is submitted on an annual basis – we will receive through December 2012).

Our CAHs currently track a Pediatric Weight process monitor. We are currently working with them to correlate this measure to ADEs in this same population.

HEN STRATEGIES FOR IMPROVEMENT: • During our “Taking Stock” site visits, we will 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 in November 2013.

o Patient/Family engagement has not been a big part of the NV HEN ADE program. We are planning a collaborative Brown Bag event with the NV QIO to do a better job at outreach to patients and including their perspective on multiple levels.

• 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 into their EMR or pre-printed order sets.

• Encourage hospitals to collect data on Medication related events related to Readmission – pilot with a volunteer hospital has begun and we should see results of that data within 30 days.

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ADVERSE DRUG EVENTS (ADE) • Bringing 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.

• Partnership 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.

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.) • 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: SUMMARY OF CAUTI AND CATHETER UTILIZATION RATES

CAUTI and Catheter Utilization Rates



%

Decrease


CAUTI Rate per 1,000 device days (NHSN) 1.43 1.63 -14%

Period Feb-Apr 2011 2Q 2013

CAUTI Rate per 1,000 device days (self-report) 3.6 2.3 31%

Period 4Q 2011 2Q 2013

Overall CAUTI Rate -3%

Catheter Utilization Rate (NHSN) 38% 28% 27%

Period Feb-Apr 2011 1Q 2013

Catheter Utilization Rate (self-report) 0.25% 0.14% 14%

Period 4Q 2011 2Q 2013

Overall Catheter Utilization Rate 19%

Non-PfP-Eligible Hospitals 6/ 9 66.7%

CAUTI Rate per 1,000 device days (self-report) 4.0 3.5 13%

Period 1Q 2011 2Q 2013

Catheter Utilization Rate (self-report) 47% 39% 18%

Period 1Q 2012 2Q 2013

Notes: Negative values indicate increase in CAUTI rate. Weighted average was used to define overall % change in the combined rate. For the NHSN data, all hospital units are used to define the CAUTI and catheter utilization rate.

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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.

Figure 6: CAUTI rate (blue line) for NHSN data over entire reporting period of PfP-eligible facilities (Baseline=12 facilities; Current= 15 facilities). In current reporting period, the CAUTI rate increased 14% from a baseline rate of 1.43 to a rate of 1.63. 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 self-report data over entire reporting period of PfP-eligible facilities (Baseline= 4 facilities; Current= 5 facilities). In current reporting period, the CAUTI rate decreased 31% from a baseline rate of 3.6 to a rate of 2.3. 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: Catheter utilization rate (blue line) from NHSN data over the entire reporting period for PfP eligible facilities (Baseline=12 facilities; Current= 15 facilities). In current reporting period, the catheter utilization rate decreased 27% from a baseline rate of 0.38 to a current rate of 0.28. The red line is a linear trend line that is fit to the baseline catheter utilization rate and current catheter utilization rate.

Figure 9: Catheter utilization rate (blue line) from self-report data over the entire reporting period for PfP eligible facilities (Baseline= 4 facilities; Current= 5 facilities). In current reporting period, the catheter utilization rate decreased 14% from a baseline rate of 0.25 to a current rate of 0.14. The red line is a linear trend line that is fit to the baseline catheter utilization rate and current catheter utilization rate.

DATA ANALYSIS AND RESULTS FOR NON PFP-ELIGIBLE FACILTIES: Six 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.

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Figure 10: CAUTI rate (blue line) over entire reporting period of nonPfP-eligible facilities (Baseline= 5 facilities; Current= 6 facilities). In current reporting period, the CAUTI rate decreased 13% from a baseline rate of 4 to a current rate of 3.5. The red line is a linear trend line that is fit to the baseline CAUTI rate and current CAUTI rate.

Figure 11: Catheter Utilization rate (blue line) over entire reporting period of nonPfP-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.

STRATEGIES AND SUCCESSES TO DATE: • 9 PfP facilities and 4 non-PfP facilities have achieved level 3 or 4 status indicating that these

facilities are decreasing CAUTI rates. • HEN staff presented to 5th Friday Club of Southern Nevada (August 30th) that is sponsored by the

Nevada Hospital Association and Nevada Organization of Nurse Leaders about Rising CAUTI and CLABSI rate: Call to Action. We asked leaders to commit to reviewing that bundles are followed and that these bundles and best practices are spread to all departments in the next 30 days. We used the Signature Style method to develop the presentation.

• Collaboration with the QIO program and CUSP CAUTI to reduce the CAUTI rate in Nevada.

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CATHETER-ASSOCIATED URINARY TRACT INFECTIONS (CAUTI) Beginning as early as 2011, fourteen hospitals have joined the in the QIO and NHA CUSP CAUTI

cohort and are receiving coaching on how to identify and properly report CAUTIs to ensure accuracy of their data.

• We had an open discussion with our facilities at the plenary sessions held in July about how to reduce CAUTI rates. Dr. Eugene Chu was a plenary speaker who reinforced the CUSP approach at the July 16th and 18th plenary sessions.

• 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 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)

• Share information and tools from the National Content Developer via newsletter, learning sessions, Health Community website and 1:1 coaching.

OPPORTUNITIES FOR IMPROVEMENT: • CAUTI rates per 1000 catheter days have been increasing within the NV HEN facilities that report

to NHSN resulting in a 14% increase (11% increase when CAUTI rate is calculated per 1000 patients days) One reason for the increase in CAUTI rates could be revised NHSN criteria which indicate a fever event as a CAUTI if any other CAUTI-related criterion exists even if the fever is suspected to have originated from a different diagnostic source such as pneumonia (http://www.cdc.gov/nhsn/acute-care-hospital/index.html). This new broader definition of CAUTI may be leading to higher CAUTI rates.

HEN STRATEGIES FOR IMPROVEMENT: • Obtain commitments from leaders in at our hospitals to review CAUTI bundle compliance within

the next 30 days. The HEN team will reach out to the hospitals in 30 days to determine whether the commitment has been successful.

• Encourage interventions such as criteria-based protocol approval that empowers nurses to remove catheters without a doctor’s order to further reduce Catheter Utilization.

• Encourage hospitals to conduct daily multi-disciplinary rounds to include assessment and actions to remove catheter or look for signs of infection.

• 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.).

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.

http://www.cdc.gov/nhsn/acute-care-hospital/index.html

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CENTRAL LINE-ASSOCIATED BLOODSTREAM INFECTIONS (CLABSI)

TABLE 5: SUMMARY OF CLABSI RATES

Central Line-Associated Bloodstream Infections



%

Decrease


CLABSI Rate per 1,000 device days (self-report ) 1.6 1.7 -5%

Period Q1 2011 Q1 2013

CLABSI Rate per 1,000 device days (NHSN) 1.3 1.2 8%

Period Q1 2011 Q1 2013

Overall CLABSI Rate 7%

Non-PfP-Eligible Hospitals 5/ 9 55.6%

CLABSI Rate per 1,000 device days (self-report ) 1.4% 1.1% 23%

Period Q1 2011 Q2 2013

Note: Combined rate is the weighted average of 2 outcome measures. Negative values indicate an increase in the CLABSI rate.

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 1Q 2011 and the current CLABSI rate is calculated over 2Q 2013. The NHSN cohort represents 64% of our PfP eligible facilities and is showing 8% improvement. For NHSN facilities, considering ICU only, central line utilization has increased 9% from baseline.

Five additional PfP-eligible facilities self-report CLABSI data bringing our total participation rate for this HAC to 86%. The baseline period for self-report CLABSI rate was 1Q 2011 and the current time period for the PfP-eligible self-reported data is 2Q 2013. This cohort is showing 5% increase in CLABSI rate.

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Figure 12: 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 5% from a baseline rate of 1.6 to a current rate of 1.7. The red line is a linear trend line that is fit to the baseline CLABSI rate and current CLABSI rate.

DATA ANALYSIS AND RESULTS FOR NON PFP ELIGIBLE FACILITIES: The NV HEN also has five non-PfP eligible facilities (LTACs & rehab) who self-report CLABSI data in the current time period (2Q 2013) and the 4 facilities are in the baseline period (first 6 months of 2011). The non-PfP eligible facilities are showing 23% reduction in CLABSI rates.

Figure 13: 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 8% from a baseline rate of 1.27 to a current rate of 1.17. The red line is a linear trend line that is fit to the baseline CLABSI rate and current CLABSI rate.

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Figure 14: CLABSI rate per 1000 central line days (blue) for non-PfP eligible facilities. In current reporting period, the CLABSI rate decreased 23% from a baseline rate of 1.4 to a current rate of 1.1. The red line is a linear trend line that is fit to the baseline CLABSI rate and current CLABSI rate. (Baseline= 4 facilities & Current=5 facilities)

HARM AVOIDED AND PROJECTED COST SAVINGS: Assuming an average of $19,000* saved per event (Table 2), we estimate that both PfP-eligible facilities reporting to NHSN saved 2 patients and had a cost savings of $38,000 in the current time period. We further estimate an annual cost savings of $152,000. We estimate our non-PfP eligible facilities have saved 2 patients with a cost savings of $38,000 during the most current quarter. We further estimate an annual cost savings of $152,000 (Table 2) for this cohort.

*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.

STRATEGIES AND SUCCESS TO DATE: • 2 facilities achieved level 3 status, 6 facilities achieved level 4 status and 2 facilities achieved a level

5 status on the participation grid • Progressive Hospital and Hospital 8, both LTAC facilities, have achieved level 5 status. We have

shared their best practices for HAI prevention across the board via success stories, poster sessions, and panel presentations. Although, not technically 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.

OPPORTUNITIES FOR IMPROVEMENT: Although still showing a 7% decrease from baseline, our CLABSI rate is increasing when compared to 3Q 2012. We are working with our facilities to gain a better understanding for these results. One potential

20

CENTRAL LINE-ASSOCIATED BLOODSTREAM INFECTIONS (CLABSI) explanation for the increase in the infection rate is the 2013 change in the definition of an HAI, from a 48

hour window to a 2 calendar day window. Since most patients arrive during the evening hours, a patient may be on calendar day 3 only 36 hours after admission. Therefore a HAI discovered at this time would be the hospital’s responsibility under the new definition whereas under the old definition it would be excluded as present on admission. Another potential explanation is that hospitals are becoming more aware that no clinical symptomology is required to report a CLABSI, nor does multi-drug resistant carriage or colonization imply “present or incubating at the time of admission”. Previously, those alternate criteria were applied as exemptions and the CLABSI was not reported. Thus, it appears that this trend may be a result of more thorough reporting and criteria adjustments in the NHSN input data. If that is so, we should see a gradual evening out of the data over time. Nonetheless, we are deeply concerned about our HEN’s rising CLABSI trend.

HEN STRATEGIES FOR IMPROVEMENT: • A Call to Action: During our NV HEN monthly call (8/29) and Nevada Hospital Association

Organization of Nursing Leadership meeting (8/30), 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). The NV HEN will follow up with the facilities individually and at our next monthly call for NV HEN members to look for action on their commitment.

• During our NV HEN monthly call (8/29), we invited 2 of our best practice Nevada hospitals (K and R) present their success strategies with emphasis on how they were able to spread and sustain the improvement.

• Although CUSP CLABSI ended in Sept 2012 – we still striving for commitment and action from our facilities to continue vigilance in bundle compliance and spread 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.

• Leverage our Level 5 hospitals (Hospital 2 & 8) strategies with their peers to move them to improve beyond their current rate.

HOSPITAL STRATEGIES FOR IMPROVEMENT: • Institute and monitor the use of the CLABSI bundles – look at process measures to measure

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.

21

EARLY ELECTIVE DELIVERY (EED)

TABLE 6: SUMMARY OF EED RATES

Early Elective Deliveries



%

Decrease


EED Rate (Self-report) 9.6% 1.4% 86%

Period Average over year

2011 2Q 2013

DATA ANALYSIS AND RESULTS: The NV HEN has 12 facilities with obstetrics departments; all 12 of these facilities are PfP eligible. Nine of the 12 facilities have self-reported data to us in the current time period of 2nd quarter 2013 which gives us a 75% participation rate. We calculate the EED rate using the 2011 average as the baseline reporting period. There are 8 facilities in the baseline time period of 2011, four of these hospitals provided 2010 and 2011 data using 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 a good 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. Our NV HEN facilities are showing an 86% reduction in EED.

Figure 15: Early elective deliveries (blue line) over entire reporting period of PfP-eligible facilities. In current reporting period, the EED rate decreased 86% from a baseline rate of 9.6 to a current rate of 1.4 (Baseline= 8 facilities & Current=9 facilities). The red line is a linear trend line that is fit to the baseline EED rate and current EED rate.

22

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STRATEGIES AND SUCCESS TO DATE:

• 86% reduction in EEDs when current time period is compared to baseline (Figure 15) • 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.

• 8 facilities have achieved a level 3 status or higher. o Three facilities have achieved level 5 status by successfully reducing their EED rates by

more than 40% and implementing and enforcing a Hard Stop Guideline.

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

ways to advance the goals. • Continue to increase the number of hospitals reporting current and historical data to obtain 100%

participation.

HEN STRATEGIES FOR ADDED SUCCESS: • Taking stock visits with two of the rural facilities to discuss hard stop and other activities are

occurring August 2nd and August 28th. • 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. Next Advisory group will meet on August 7th. • 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.

23

FALLS WITH SIGNIFICANT INJURY

TABLE 7: SUMMARY OF FALLS TRAUMA RATES

Falls Trauma Rates



%

Decrease


Falls Trauma Rate per 1,000 discharges (CHIA) 1.24 0.65 47%

Period 1st six

months 2010

1Q 2013

Falls Trauma Rate per 1000 discharges (self-reported)

0.02 0.19 3%

Period 1st six

months 2010

Mar-May 2013

Overall Falls Rate 43%

Non-PfP-Eligible Hospitals 5/6 83%

Falls Trauma Rate per 1,000 discharges (CHIA) 3.1 0 100%

Period 1st six

months 2010

Q1 2013

DATA ANALYSIS AND RESULTS: We track Falls Trauma 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 criteria. We have already begun querying our facilities to determine data access and we believe many of our facilities will be able to provide # of falls/# of patient days.

Twenty-four 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

24


rate was calculated using the first 6 months of 2010 and the current fall trauma rate was calculated using Q1 2013 (Figure 16). Within this cohort, falls trauma rate improved by 47% in the current time period compared to baseline. Two PfP-facilities self-report data on falls with injury. This self-reporting cohort showed a 3% decrease in falls trauma rate from the baseline (1H2010) to the current period (Mar-May 2013). The overall HAC rate of improvement of 43% was calculated by taking a weighted average of the falls trauma rate for the 22 PfP-eligible CHIA facilities and the 2 PfP-eligible facilities self-reporting data. For non-PfP facilities, we obtained data from CHIA as well as self-reported data. We obtained data from 5 facilities from the CHIA database during the current time period. The baseline period for this cohort was the first half of 2010 average and the current reporting period was defined as Q1 2013. The 4 non PfP eligible facilities self-reporting data reported zero falls with significant injury during Q1 2013.

Figure 16: 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 47% from a baseline rate of 1.24 to a rate of 0.65 (Baseline = 24 facilities & Current = 22 facilities). The red line is a linear trend line that is fit to the baseline Falls Trauma rate and current Falls Trauma rate.

Figure 17: 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 100% from a baseline rate of 3.1 to a rate of 0.00. (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.

25


ADDITIONAL DATA • Two PfP-eligible facilities self-report data as the number of falls at their facilities that result in

serious injury (according to the CMS HAC definition for Falls Trauma) per 1,000 discharges. This self-reporting cohort showed a 3% decrease in falls trauma rate from the baseline (1H2010) to the current period (Mar-May 2013).

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 27 patients from harm during the current quarter with a total projected annual cost savings of $1,215,000 (PfP-eligible facilities: $1,170,000 and non-PfP-eligible facilities: $45,000).

*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: • 21 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 geri-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

HEN STRATEGIES FOR ADDED SUCCESS: • Share the strategies of our successful hospitals with others to spread best practices • Even though our data collection measures and tracks the high-harm events, our interventions

strive to eliminate all falls. During 1x1visits we make sure our facilities 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 1:1 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 • Share information from pacing events, national toolkits and success stories on the monthly calls,

monthly newsletter, and educational sessions.

26


HOSPITAL STRATEGIES FOR ADDED SUCCESS: • Patient-Family Engagement strategies geared to partner in 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

27

OBSTETRICS ADVERSE EVENTS

TABLE 8: SUMMARY OF OBSTETRICS ADVESRE EVENTS RATES

Obstetrics Adverse Events



%

Decrease


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

0.16 0 100%

Period 1st six

months 2010

1Q 2013

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

150 128 15%

Period 1st six

months 2010

1Q 2013

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

26 18 32%

Period 1st six

months 2010

1Q 2013

Overall OB Adverse Event Rate 49%

Note: Combined rate is average of 3 outcome measures (all have 100% reporting)

DATA ANALYSIS AND RESULTS: The NV HEN has 12 facilities with OB departments and all are PfP-eligible. The NV HEN uses medical billing data from the CHIA database to track OB adverse events using three outcome measures: injury to neonate, injury due to vaginal births with instruments and injury due to vagina births without instruments. Using the CHIA database we are able to achieve 100% reporting. Baseline reporting period for all three measures is the first half of 2010 and the current report time period is Q1 2013. We calculate the overall improvement rate of 49% for other OB Adverse Events by taking an average of the 3 outcome measures.

28


Figure 18: 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. 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 19: 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 15% from a baseline rate of 150 to a current rate of 128. 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.

29


Figure 20: 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 32% from a baseline rate of 26 to a current rate of 18. 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), we estimate that in the current time period our facilities saved 36 babies and mothers from injury or trauma and saved $108,000 in Q1 2013 (Table 2). We further estimate an annual cost savings of $432,000.

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. • Two 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 2 years 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.

• One of our rural facilities has an employee who is master trainer in Advanced Life Support in Obstetrics (ALSO) and is working on training emergency responders in Life Support for Obstetrics.

• The use of Mid-Wives (in 2 of our facilities) has decreased harm associated with the use of instruments

• Training facilitation provided via University of Nevada, School of Medicine (UNSOM) ALSO project and HEN best-practice examples has 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

• OB Advisory Committee was created as a forum for experts in the area of maternal health and obstetrics from our facilities and the community to share best practices and discuss emerging trends and issues.

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

30

OBSTETRICS ADVERSE EVENTS OPPORTUNITIES FOR IMPROVEMENT:

• The Nevada HEN OB Advisory Committee participation has diminished – we are reaching out to leadership to stimulate meaningful participation and attendance.

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

• Through UNSOM project, provide additional focused training that can be spread to other areas of the hospital (e.g. ER) and to other hospitals in a region.

• Encourage hospitals to participate in the UNSOM training in the 3rd year

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)

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

31

PRESSURE ULCERS

TABLE 9: SUMMARY OF PRESSURE ULCER RATES

Pressure Ulcers



%

Decrease

PfP-Eligible Hospitals 24/ 25 96%

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

0.95 1.07 -12%

Period 1st six

months 2010

1Q 2013

Non-PfP Eligible Hospitals 6/7 100%

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

10. 19 1.76

Period 1st six

months 2010

1Q 2013 83%

Note: 2 PfP-eligible facilities not included in the current CHIA data are self-reporting pressure ulcer data. One facility has had 0 events in over 3 years and the other has not provided baseline data, therefore neither facility is included in the overall HAC rate.

DATA ANALYSIS AND RESULTS: We track Stage 3 & 4 Pressure Ulcers using the CHIA database and exclude diagnoses according to the AHRQ definition. We also collect self-report data on Stage 3 and 4 pressure ulcers from two PfP eligible facilities that are not included in the current time period of the CHIA database. These facilities are not included in the overall HAC improvement rate because one facility has not provided benchmark data and the other has had a sustained zero rate for 3 years.

When we look at PfP eligible facilities and non-PfP facilities separately, we observed rates of 12% increase and 83% decrease respectively. Interesting to note, when comparing 2011 average to Q1 2013 average for PfP eligible facilities there is a 30% decrease in the pressure ulcer rate which demonstrates our facilities are moving in the right direction.

The fact that the rate for our PfP eligible facilities is higher in the current time period than the baseline period may partially be due to our facilities’ efforts to improve identification and reporting of pressure ulcers; however, we continue to make this HAC a priority. We strive to spread the improvement we have seen with our non-PfP eligible facilities throughout our network and we are confident that the PfP facilities will begin to show improvement soon.

32

PRESSURE ULCERS

Figure 21: 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 increased 12% from a baseline rate of 0.95 to a rate of 1.07. (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 12: 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 83% from a baseline rate of 10.19 to a rate of 1.76. (Baseline=7 facilities; Current=7 facilities). The red line is a linear trend line that is fit to the baseline pressure ulcer rate and current pressure ulcer rate

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 • PfP eligible hospitals are showing a 30% decrease from 2011 avg. to Q1 2013. • Non-PfP eligible facilities showing a 83% decrease from 2010 baseline (Figure 22)

33

PRESSURE ULCERS • Improved coding and identification of Pressure Ulcers vs. various other skin conditions.

• HEN facilities front line wound care clinicians attended a seminar presented by nationally recognized expert on pressure ulcers (Dr. Joyce Black) May 14, 2013 increasing their knowledge of identification and documentation of wounds.

OPPORTUNITIES FOR IMPROVEMENT: • 12% increase of Pressure Ulcer rates from baseline of the PfP eligible facilities reporting via the

CHIA database. • The two non-PfP eligible facilities who are self-reporting data show a rate increase of 12%

HEN STRATEGIES FOR IMPROVEMENT: • Convene the Pressure Ulcer Advisory Team (Wound Nurses, Nutritionists, Physical Therapists) at

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

• 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 vac system

• Continue to share the strategies of successful hospitals to spread best practices • Provide additional 1:1 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) • Share information from pacing events, toolkits and success stories via newsletter, monthly call and

education sessions. • Train facilities to look for signs of deep tissue injury and LOOK BACK 24-72 hours to identify

causative event and location.

HOSPITAL STRATEGIES FOR IMPROVEMENT: • 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

34

READMISSIONS

TABLE 10: SUMMARY OF READMISSION RATES

Readmissions



%

Decrease


Readmissions Rate (CHIA) 12% 11.4% -5.4%

Period 1st six

months 2010

1Q 2013

Readmissions Rate (Self-Report): 1 PfP eligible facility not included in the current CHIA data self-reports “Returns to Tertiary Setting” within 30 days of discharges

2011 Average

Feb-Apr 2013 23%

Overall Readmissions Rate 6%

Non PfP Eligible Hospitals 7 / 8 88%

Readmissions Rate (CHIA) 22.8% 22.5% 1%

Period 1st six

months 2010

1Q 2013

35

READMISSIONS

DATA ANALYSIS AND RESULTS: Our primary data source for 30-day All-payer Readmissions is the CHIA. The NV HEN calculates the readmission rate similar to the method used by the National Coordinating Center for Care Transitions. We use a SAS code (SAS Institute software analysis program) that counts unique patient identifiers who have an admission within 30 days of a discharge. From this sample, we exclude same day readmissions, transfers, rehab visits, visits without unique patient identifiers, and children. In the current reporting period, CHIA results show a 5.4% reduction in readmissions rate of our PfP-eligible facilities from baseline compared to the current reporting period (Figure 23). We calculate the overall readmissions rate (6%) by taking a weighted average of our 22 PfP-eligible facilities in the CHIA database and the 1 PfP-eligible facility self-reporting readmissions data. (See Table 1)

For our non-PfP eligible facilities, readmission rates decreased 1% during the current reporting period compared to baseline (Figure 24).

According to CMS analysis of readmissions rates for the Fee-for-Service (FFS) Medicare population, the NV HEN facilities have improved by more than 7% from a 2010 baseline. This analysis puts the NV HEN in the top 5 among HENs nationally for readmissions rate improvement.

Figure 13: 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 (Q1 2013), the average readmission rate decreased by 5.4% from the 1H 2010 baseline rate of 12.0% to a current rate of 11.4%. (Baseline=24 facilities; Current= 22 facilities). The red line is a linear trend line that is fit to the baseline readmission rate and current readmission rate

Note: One additional PfP-eligible facility self-reports data from their "Returns to Tertiary Setting". They are showing a 23% reduction in readmissions between 2011 and Feb-Apr '13.

36

READMISSIONS

Figure 24: 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 (Q1 2013), the average readmission rate decreased 1% from baseline rate of 22.8% to a current rate of 22.5% (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.

Note: Two additional non-PfP facilities are self-reporting data on 30-day readmissions. These facilities are showing an increase in the rate.

HARM AVOIDED AND PROJECTED COST SAVINGS: Assuming a cost of $9,600 per readmission, we estimate that our PfP eligible facilities represented in the CHIA database saved 191 patients from harm and saved $1,833,600 in Q1 2013. We further estimate an annual cost savings of $7,334,400 (Table 2). Among non-PfP facilities, we estimate that our facilities saved 2 patients by reducing readmissions and realized a cost savings of $19,200 in Q1 2013. We further estimate an annual cost savings of $76,800 (Table 2) for non-PfP eligible facilities.

STRATEGIES AND SUCCESSES TO DATE: • 14 of our PfP facilities have achieved a level 3, 4 or 5 on the Participation Grid. • Education and Toolkits: This topic was a focus of our recent July Plenary sessions. We obtained a

national speaker, Dr. Saranya Loehrer from IHI, discussed readmission prevention strategies. She co-presented with Donna Thorson, from the NV QIO, who show-cased the existing programs in Nevada that are available to advance our readmission success rate.

• According to CHIA data, one non-PfP-eligible facility (Hospital 6) has successfully reduced their readmissions rate by 66% comparing their 2011 and 2012 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.

37

READMISSIONS • 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 will present 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. • Our non PfP eligible facilities are only showing a 1% improvement in readmissions rate comparing

a baseline time period of the 1st half of 2010 with the 1st quarter of 2013.

HEN STRATEGIES FOR IMPROVEMENT: • Work with our facilities 1x1 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 so that more specific

avoidance action plans can be developed. 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 (blinded facility 9) whose strategies might help the others. We are leveraging that information 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, we are:

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 QA Division 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 60% of Medicare patients who appeal

38

READMISSIONS 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. 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.

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 Some facilities are utilizing a call center to follow up with patients about their primary care physician appointments

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 some success as patients return for other services with an updated card in hand.

• Technology: Hospital 6 has plans to 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)

39

SURGICAL SITE INFECTIONS (SSI)

TABLE 11: SUMMARY OF SSI RATES

Surgical Site Infections (SSI)



%

Decrease


SSI Rate from colon procedures (NHSN) 0.04 0.03 21%


March-May 2013

SSI Rate from hysterectomy (NHSN) 0.005 0.004 21%


March-May 2013

All SSI Rate (self-reported) 0.011 0.006 50%

Period Jan-June 2011

March-May 2013

Overall SSI Rate -3%

26%

Note: Weighted average of 3 outcome measures was used to define % change in combined rate.

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 19 facilities that perform surgeries; 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 Q1 2012. The current time period used to calculate the rate of SSIs from COLO procedures and SSIs from HYST was March-May 2013. For the self-report data, the rate of SSIs from ALL surgical procedures was calculated over the baseline period of 1st half of 2010 and over three month period (March –May 2013).

There are 15 facilities represented in the current time period of the NHSN SSI from Colon procedures measure and 12 of those facilities also provide NHSN SSI data from Hysterectomies. The NHSN cohort has achieved a 21% SSI rate reduction for both types of procedure.

We are also showing strong SSI rate reduction among facilities who self-report SSIs from all procedures. This cohort is also showing a 50% improvement. Two of the facilities self-reporting SSI data are not included in the NHSN cohort; this gives us an overall HAC participation rate of 89% (17 out of 19 facilities).

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Figure 25: The # 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 # of SSIs from COLO procedures decreased 21% from a baseline rate of 0.04 to a rate of 0.03. (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 26: The # 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 # of SSIs from HYST procedures decreased 21% from a baseline rate of 0.005 to a rate of 0.004 (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 27: The # of SSIs from ALL procedures per total # of surgical procedures over the entire reporting period for self-reported PfP eligible facilities. In the current reporting period, the # of SSIs from ALL procedures decreased 50% from a baseline rate of 0.011 to a current rate of 0.006. (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 most recent 3 months, our data indicates that the hard work of our facilities resulted in an avoidance of 3 potential SSI associated with Colon Surgery at an estimated cost savings of $60,000 per event*, projecting an annual cost savings of $240,000 (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, 21% decrease from baseline

(Figure 25) • Hysterectomy related SSI rate (12 facilities) also showing a 21% from baseline and is pacing below

national averages overall (Figure 26) • Self-Report - [All SSI]/[All Surgeries], 5 facilities, 50% decrease from baseline (Figure 27). Two of

these facilities are not included in the NHSN data. • 11 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). This group also sponsored a survey of all the hospitals in the state to identify the degree of antibiotic stewardship programs that are in place and to identify those in need so that a toolkit for justification (and implementation) can be developed.

• The Nevada Division of Health partnered with the NV HEN and the NV QIO to conduct training during July 2013 conference on infection prevention about Multi-Drug Resistant Organisms prevention and treatment strategies.

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

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OPPORTUNITIES FOR IMPROVEMENT:

• We must accelerate the reduction of the SSI rate for colon procedures and hysterectomies in order to achieve our goal of 40% rate reduction by the end of 2013.

HEN STRATEGIES FOR IMPROVEMENT: • 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 provide additional 1x1 assistance as needed to facilitate Incident Investigation and Root Cause

Analysis (RCA) for SSI events to identify causes and solutions to mitigate future high-harm events. RCA training was conducted in May 2013.

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

HOSPITAL STRATEGIES FOR IMPROVEMENT: • Participation in the SUSP project. The HEN is sponsoring two hospitals in the SUSP project (Cohort

2) that are now engaged in NHSN data upload to SUSP. We anticipate 1-3 more to sign up for cohort 4, starting in October.

• 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.

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VENTILATOR ASSOCIATED PNEUMONIA/ EVENT (VAP/VAE)

TABLE 12: SUMMARY OF VAP/VAE RATES

Ventilator Associated Pneumonia (VAP)/Ventilator Associated Events (VAE)



%

Decrease


VAP Rate per 1,000 ventilator days (CHIA) 6.04 3.17 48%

Period 1st six

months 2010

1Q 2013

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

6.56 0 100%

Period 2010 Average 1Q 2013

Overall VAP Rate 55%

Non-PfP-Eligible Hospitals 6/ 9 67%

VAP Rate per 1,000 ventilator days (CHIA) 1.84 0.48 74%

Period 1st six

months 2010

1Q 2013

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

0 0 Maintenance of 0 rate

Period Jun-Aug 2012

Mar-May 2013

DATA ANALYSIS AND RESULTS: To calculate the VAP rate use CHIA data or self-report data from facilities not in the current time period within the CHIA data set. Twenty of our PfP eligible facilities have ventilator capabilities and we have 19 PfP eligible facilities in the current time period of our data giving the NV HEN 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 Q1 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 March-May2013; this cohort has had no VAPs for 5 months. The overall VAP rate of 55% improvement was calculated by taking a weighted average of the improvement rates from the two PfP-eligible cohorts.

44

VENTILATOR ASSOCIATED PNEUMONIA/ EVENT (VAP/VAE) For non-PfP eligible facilities, the VAP rate was calculated for the CHIA cohort over a baseline period of the

first half of 2010 and the current reporting period of the first quarter 2013. We also have 2 non-PfP facilities that self-report who have had zero events for two years. The non-PfP eligible facilities are not included in the overall percent improvement per HAC.

Figure 28: 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 48% from a baseline rate of 6.04 to a rate of 3.17. (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 29: 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. (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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Figure 30: 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 74% from a baseline rate of 1.84 to a rate of 0.48. (Baseline=7 facilities; Current=6 facilities). The red line is a linear trend line that is fit to the baseline VAP rate and current VAP rate.

HARM AVOIDED AND PROJECTED COST SAVINGS: We estimate, in the current 3 month time period, that the hard work of our PfP facilities resulted in an avoidance of 19 potential VAP related events corresponding to a cost savings of $817,000*. We estimate an annual cost savings of $3,268,000 (Table 2). Our non-PfP eligible hospitals prevented 2 events in this period with an annual projected savings of $344,000.

* $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: • 5 PfP facilities achieved level 3 status, 7 PfP facilities achieved level 4 status and 1 PfP facility

achieved level 5 status. • Hospital H achieved a level 5 status because even though they have not had a VAP in over 3 years

they are still actively trying to reduce chance of infection by reducing the average number of ventilator days per patient on a ventilator and implementing sedation vacations every morning.

• Earlier this year, the NV HEN Respiratory Advisory Committee cross-walked new VAE data collection for NHSN reporting to ensure accurate and useful hospital-specific trending data. Their assessment is that the new criteria will be more accurate in targeting a true VAE and accept that the lengthier analysis is worth the effort

OPPORTUNITIES FOR IMPROVEMENT: • Emphasize sedation vacations, ambulation, and other strategies to allow more effective ventilator

care. • Continue assessment of facilities for implementation and understanding of new NHSN criteria for

VAE. During our Taking Stock visits, we are assessing their readiness and understanding. We are

46


happy to report that the majority of our eligible facilities have already successfully converted and like the new tool.

• 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. • Provide additional 1x1 assistance as needed to facilitate root cause analysis (RCA) for VAE events

to identify causes and solutions to mitigate future high-harm events. • We share information from pacing event, toolkits, and success stories, via newsletter, monthly call

and plenary sessions. • During “Taking Stock” visits, validate that they understand and can 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.

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)

TABLE 13: SUMMARY OF VTE RATES

Venous Thromboembolism (VTE)



%

Decrease


VTE Rate per 1,000 discharges (CHIA) 4 3 24%

Period 1st six

months 2010

1Q 2013

Non-PfP-Eligible Hospitals 6/ 9 67%

VTE Rate per 1,000 discharges (CHIA) 25 9 65%

Period 1st six

months 2010

1Q 2013

DATA ANALYSIS AND RESULTS: We calculate the VTE rate by querying pulmonary embolisms (PE) and deep vein thrombosis (DVT) from the CHIA database for our PfP and non PfP eligible facilities. The VTE rate for our PfP eligible facilities and non-PfP eligible facilities was calculated using the first 6 months of 2010 as baseline period and Q1 2013 as the current reporting period.

Figure 31: VTE rate per 1000 discharges for PfP eligible facilities. In current reporting period, the VTE rate decreased 24% from a baseline rate of 4.02 to the current rate of 3.07. (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 32: VTE rate per 1000 discharges for non-PfP eligible facilities. In current reporting period, the VTE rate decreased 65% from a baseline rate of 25 to the current rate of 9. (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.

HARM AVOIDED AND PROJECTED COST SAVINGS: The cost of the average VTE* is approximately $10,000. We estimate that the hard work of our facilities prevented 52 patients from harm per quarter with a projected annual cost savings of $2,080,000 (PfP eligible facilities; $1,680,000 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: • 88% data participation • 5 facilities achieved level 3 and 8 of our facilities achieved level 4 status • 24% decrease from baseline PfP eligible facilities (Figure 31). This is a 3% improvement over the

4Q 2012 rate for this cohort. • 65% decrease from baseline for non-PfP eligible facilities (Figure 32)

OPPORTUNITIES FOR IMPROVEMENT: • Encourage our facilities to enhance program to achieve level 3 status or higher

HEN STRATEGIES FOR IMPROVEMENT: • 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

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

49


• Correlate this HAC with the ADE HAC to minimize adverse drug events when anticoagulants are indicated.

• Correlate this HAC with Pressure Ulcer prevention by re-assessing use of TED hose or other devices

• Provide additional 1x1 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 IMPROVEMENT: • 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. • 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 we have 44% (11

out of 25) of our PfP eligible members meaningfully engaged in this valuable partnership with the patient/family.

o Boulder City Hospital has a Patient and Family Advisory Committee in place that is facilitated by the consumers with the goal of establishing a forum to discuss quality of care issues from a 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 in place. As a committee member, the NV HEN able to spread best practices across the HEN. This committee has established as a goal to broaden the scope of involvement of by past patients or family members to discuss “lessons learned” with the mission to implement change as needed to address quality issues. This committee has scheduled to meet consistently on a quarterly basis, with subgroups meeting more frequently as needed. Physicians are actively participating in this group. Several changes influenced by patient comments have already been implemented at hospital, from changes in signage and visitor hour policies to discipline of staff and procedure changes.

o The VHS system (pilot to begin at Hospital J and then spread to the remaining 4 PfP HEN hospitals in their local network); 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 One NV HEN Critical Access Hospital (CAH) is partnered with PlaneTree which focuses on patient-centered care.

• At least three of the hospitals (H, V & 6) have CEOs who conduct weekly rounds at their facilities. • At one facility (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. • Community members attended our Plenaries (See High-Level Executive Summary, PFE

Engagement section). We recognized these individuals with “Together We Can” ribbons on their nametags and distributing them throughout the room to encourage interaction and discussion.

• Partnering with The ROYL (Rest of Your Life Planning) to help educate patients and engage them in their own care – they will begin a pilot with Hospital K and then we can roll out to the other ACH.

• CEO, Kimball Anderson presented his approach to developing the Patient Advisory Committee to his peers at an American College of Healthcare Executives event on June 27. The information was well received and prompted interest from several facility administrators to make this priority.

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

• The July 2013 Plenaries provided excellent platform to continue to promote the culture change towards Patient /Family Engagement:

o The Nevada HEN brought in a representative from the Cleveland Clinic Foundation (CCF) to speak to the attendees regarding the evolution of CCF’s Office of Patient Experience including the catalyst and implementation for their culture change which they were able to achieve in a relatively short time across a large organization. This provided our facilities with the confidence and knowledge to “take the leap” to move forward with their programs.

51


o The NV HEN also invited patient representatives to both the northern and southern plenary sessions. In the northern plenary, Jim Wittenberg spoke to attendees about his personal experience with the healthcare system, how quality affected his care (positively and negatively), why it is necessary to consider the patient as the most important piece in the process and why it is imperative that they are closely involved. Mr. Whittenberg made himself available throughout the day to field questions from attendees. This was a very positive interaction for both Mr. Whittenberg and the plenary attendees.

o In the southern plenary, our 2 PFE participants (non-clinical representatives from HomeWatch Caregivers) engaged with our speakers and HEN attendees to relate the patient perspective and barriers they encounter. As patient advocates, they added a unique perspective to discussions and took away many resources, contacts and programs that will help them in their mission to be the bridge for the homebound to the healthcare systems. This interaction was valuable and impactful by creating new alliances and spreading knowledge of available resources.

OPPORTUNITIES FOR IMPROVEMENT: • Work with Risk Managers and Leadership to embrace the value of Patient/Family engagement • Assist the hospitals in the interpretation of HCAHPS (consumer satisfaction) scores as they relate

to PFE activities. However, continue to remind them that this is a monitoring tool and not the basis for the Advisory group 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 more patients in the efforts and offerings of the HENs and information on Patient-Family Engagement

• NV HEN to sponsor a Patent/Family Engagement Advisory group so that our facilities can network and share strategies and successes. – Sept 2013

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

needed to facilitate improvement of seamless efforts across organizational levels to share best practices.

• 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, monthly newsletter, and educational sessions.

• Collaboration with other groups to partner in this effort

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

52


• Patient-Family Engagement strategies geared to partner in prevention • 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 their 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. • Bedside Huddles to allow patient and family to observe and participate in care decisions. • Engaging patient and families in quality improvement efforts. • 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: • 2 PfP facilities achieved level 3 status, 17 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. A second topic is also being developed for a future meeting.

• Movement toward addressing “Harm Across the Board” is progressing at a fast pace. We are sharing the data from almost 1/3 of our PfP eligible hospitals who have achieved a 3 or better status in 5 (or more) HACS (or 50% of applicable HACs).

• The NV HEN sponsored Dr., Tim MacDonald to speak at the NHA Annual Meeting in Lake Tahoe, NV (September 4 and 5). The predominant attendees are C-Suite and Board Members from across the State. Our goal was to make a peer-peer connection regarding the PfP and HEN goals and the importance of Patient Family Engagement. During that same meeting, our Bright Spots Success Stories were displayed for viewing and interaction and Marissa Brown did an overview of the HEN accomplishments and challenges, to date.

OPPORTUNITIES FOR IMPROVEMENT: • Having more facilities achieve “Harm Across the Board” status –developing a strategy to provide

initial Harm Across the Board Templates for each facility to help them see the value of the tool. During the NHA annual meeting, Marissa Brown will be presenting some of the aggregate HEN data and connecting that to the profound impact on patient lives and cost control.

• Increase attendance of Leadership to Plenary and Webinars. We are trialing the auto-appointment process to get the events onto their calendars without extra registration effort.

• We are offering the opportunity to our CEOs to attend a conference in San Mateo, CA this October to hear Dr. Reinerhart speak. If there is negligible attendance, we have a Plan B: we are considering sponsoring him or Dr. Chessare to speak in Nevada at an ACHE convening.

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

across senior leadership • We will provide additional 1:1 assistance as needed to facilitate improvement of seamless efforts

across organizational levels • Sharing information from Pacing Events, articles and success stories through the monthly calls,

monthly newsletter, and educational sessions. • Leveraging the competitive nature of the market to inspire action

HOSPITAL STRATEGIES FOR ADDED SUCCESS • Mentor hospitals will share strategies for improvement with other hospitals • Patient-Family Engagement strategies geared to partner in prevention

54

LEADERSHIP ENGAGEMENT

• Senior Leadership to promote quality vision across organizational levels and be physically present to engage front line employees, patients and families

• Engaging Bed-side staff in Safety Initiatives and Committees (Newsletters, “Town Hall Meetings”, Committee appointment, Share the safety goals AND metrics.

• “Guardian Angel” bedside visits by Senior Staff to discuss care with the patients/family • Pursuit of “Magnet” status or other similar affiliation (i.e. PlaneTree; Virginia Mason

Transformational Care Model, NICHE) • Daily patient rounding by senior leadership, department directors and managers • Utilizing a true “team” approach to quality improvement with interaction across all levels. • Actively engaging patient and family in quality improvement efforts

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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 September 2013.

• “Taking Stock “1:1 meetings to stimulate data flow, provide tools, and best-practice in areas in need of improvement.

• Continue monthly teleconference for participants – focus on providing education, speakers, tools and technical assistance to assist in attaining the goals (September topic – PFE the Southern Hills Experience).

• Bed- Mapping, Movement Memory Stick & Prevena Wound Vac (Pressure Ulcers), further investigation and sharing for intervention compliance.

• Pilot the ROYL program in a few ACH and CAH facilities for life planning strategies. Interweave POLST toolkit training to prepare clinicians to discuss end-of-life with patients and family.

• Investigate the synergy of the new Sentinel Event reporting legislation and national HCAHPS to the HAC and Harm Across the Board goals. Since this information will be of public transparency domain, the HEN will have access to this data as a comparative supplement to our own data collection.

• 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 – possible recruitment of other hospitals in an upcoming cohort 4.

• Review the last CPARS Performance Evaluation when available. Complete the upcoming Performance Self-Evaluation and Plan for 3rd Year Renewal.

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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: AUGUST 1-31, 2013: $113,824 BALANCE-TO-DATE: $418,480

ATTACHMENTS**: 1. List of Hospitals/Participation Grid

2. NV HEN Measure ReportingTemplate - Outcome measures

3. NV HEN Measure ReportingTemplate - Process measures

4. HEN Aggregate dashboard template

5. Table 1: Cost Table

6. Table 2: Summary Table

** 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.”

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