Nevada hospital engagement network -...

Nevada Hospital Engagement Network

Monthly Report

Centers for Medicare & Medicaid Services Partnership for Patients Initiative

August 9, 2013

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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]

HIGH LEVEL 30 DAY EXECUTIVE SUMMARY

In this monthly report, we have obtained 60% or greater participation from our facilities in reporting HACs plus readmission rates (Figure 1). Our facilities are demonstrating greater than 40% reduction in 5 HACs and greater than 17.6% in 3 HACs (Figure 2).

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

Figure 2: Percent improvement in each HAC and readmission rate. 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)

SUCCESSES:

PARTICIPATION RATE: We are successfully reporting above the 60% threshold for 11 of the 11 Hospital Acquired Conditions (HACs) for PfP-eligible facilities,

IMPROVEMENT RATES: Five 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). Three other HACs has improved more than 17.6% but not yet achieved 30% reduction (PfP-eligible).

HARM REDUCTION IMPACT: We estimate that the reductions in harm achieved by our facilities will save more than 2400 patients from harm and more than $22 million annually (Table 2)

PATIENT-FAMILY ENGAGEMENT (PFE) PROGRESS: Southern Hills held another Patient/Family Advisory Board meeting where Terry Woolery represented the HEN. We are seeing tangible hospital actions from suggestions made by this group. We also focused on PFE at our recent Plenary Sessions. At the southern Plenary Session, non-clinical home-care representatives shared the perspectives of homebound patients. The home-care representatives interacted with plenary attendees and provided insight to the challenges and barriers a homebound patient may encounter. In turn, hospital representatives provided information on programs and services that are available in the community. We believe this interaction helped to bridge the gap between the patients and providers. At the northern Plenary, a patient representative from Renown HealthCare’s NICHE (Nurses Improving Care for Health-system Elders) program attended and spoke of his experiences. He verbalized that he is seeing tangible changes at Renown based on the input of patients and family. He intends to share information about the HEN goals and outcomes with the NICHE group and to help us engage more patients to attend and participate in our meetings. All of the PFE attendees have been added to our distribution lists and receive our Newsletter and learning session announcements. We are working hard to build an interactive PFE base.

READMISSION DATA SHOWS IMPROVEMENT. The NV HEN PfP hospitals have achieved an overall 6% improvement in Readmission rates Q1 2013 as compared to baseline. (see Readmission section) As part of our efforts to continue reducing readmissions rates, we are collaborating with The ROYL (Rest of Your Life Planning) to engage 1-2 ACH and 1-2 CAH to pilot their program. The ROYL focuses on providing a living will and advance directive for patients. This program could avoid readmissions that are against the patient’s wishes. ROYL is also working with SNFs and LTACs on this goal. If we can get facilities across the continuum to partake of their web-based tools and live training to show positive results, we can then model the roll-out across the continuum.

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.

RURAL HOSPITALS: We are coordinating with Project ECHO Nevada (University of Nevada School of Medicine) to provide basic microbiology training for clinical professionals in our rural facilities. Project ECHO provides flexible education opportunities via video teleconference (VTC) tele-health link and records sessions for later review and CEU access.

PLENARY SESSIONS: We conducted a Southern and Northern Plenary event on July 16 and 18, entitled “Taking Action; Making a Difference”. Our goal was to provide tangible action plans that the hospitals could run with. We had 3 excellent national speakers: Dr. Saranya Loeher (IHI) spoke on Readmission Strategies; Stacie Pallotta from the Cleveland Clinic presented their journey in PFE


and Dr. Eugene Chu presented how the CUSP principles can be used as a blueprint for culture change on any topic. We also supplemented those presentations with the local perspective of what programs already exist in Nevada and a data overview of the aggregate HEN results and a poster session of our facilities’ success stories. Reviews were very positive.

MONTHLY HEN CALL – The focus for our July call was the Harm Across the Board. By request of the NV HEN, the NCD provided training to our facilities on the new template. This training was also made available to other HENs. The goal is to educate the hospitals on the execution of the tool and the utilization of the resulting data analysis to drive change at their facility. We are investigating the option of the NV HEN to provide these analyses to the facilities with some modification in hopes that they will find them useful enough to take over the process.

ADVERSE DRUG EVENTS (ADE) – We have finally achieved the 60% participation rate! We attribute this improved participation rate to offering more measurement options to our facilities and continuing to develop 1:1 relationships with Pharmacy leads. At the Aug 5 pacing event, the NV HEN presented success strategies and 1 NV HEN shared a medication reconciliation best practice.

FALLS WITH INJURY data is showing 43% overall improvement with 92% data participation. Some hospitals have requested assistance to eliminate ALL falls predominantly within specialty populations, such as neuro-psych. We are providing technical assistance through the falls program of Touro University. Also, we shared the AHRQ Falls toolkit and Nevada HEN success stories of how others have achieved improvement during our June Monthly HEN call. NCD recently performed a literature search and provided us with additional best-practice resource kits to share. We are also polling our facilities regarding their internal measures on all falls with the intent of incorporating these measures in the future.

AREAS FOR IMPROVEMENT:

CENTRAL LINE ASSOCIATED BLOOD-STREAM INFECTIONS (CLABSI) is still showing improvement from baseline, but the rate has increased incrementally over recent months. We polled our facilities to gain a better understanding for these results (see details in CLABSI section). We will continue to work with our hospitals during our “Taking Stock” visits to ensure that the CLABSI toolkits and interventions are applied to all settings, not just selected units. We are also offered a session on the CUSP method at our plenary in July that can serve as a tool to further decrease CLABSI rates. In addition, we will leverage our Level 5 hospital strategies with their peers to help move them to improve beyond their current rate.

ADVERSE DRUG EVENTS (ADE) Although we have reached the 60% overall participation rate, our aggregate improvement threshold (23%) is only slightly over half of target improvement goal – but all three of our primary monitors are trending downward. Data is showing 29% decrease in Narcotics ADE and 17% decrease in Insulin monitors, and the Warfarin/INR monitor is showing an decrease of 13%. This is the first reporting period where the Warfarin monitor is showing improvement, which can be attributed to better screening and monitoring, use of evidence-based protocols, and depletion/removal of the B-D Vacutainer blood collection tubes which had lead to inaccurate results at the end of 2012. For more details, see the ADE section of this report.

PRESSURE ULCERS (STAGES III AND IV) remains a challenge. We have northern and southern Advisory Committees that have been working on strategies and discussing new technologies and best practices. 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 learned about Prevena, which is a battery-powered, portable, disposable wound vacuum that the hospital is charged for only upon achieving successful results. We are educating


our facilities on this tool as a potentially valuable resource to ensure compliance with prescribed and mandatory PU prevention measures. For more details, see the Pressure Ulcer section of this report.

READMISSION is showing improvement, but remains below target. We are partnering with our QIO to advance strategies across the continuum of care. 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: Cost Savings and # of Patients Saved from Harm per HAC for PfP eligible and non-PfP eligible facilities

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READMISSIONS

Readmissions Data Source:

CHIA and self-report

% of Hospitals PfP-Eligible Hospitals Reporting:

92% (23/25 hospitals)

% of Reduction in Harm (PfP-Eligible Hospitals):

Overall 6% decrease from baseline

(weighted average)

Figure 3: 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 rate of 11.4%. (Baseline=24 facilities; Current= 22 facilities)

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.

READMISSIONS

Figure 4: 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 2010

baseline rate of 23% to a rate of 23% (Baseline=8 facilities; Current= 7 facilities).

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

DATA ANALYSIS AND RESULTS:

Our primary data source for 30-day All-payer Readmissions is the CHIA database (see “Nevada HEN Data Sources” p. 7). 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 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 3). 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 4).

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.

SUCCESSES:

12 of our PfP facilities have achieved a level 3 or 4 on the Participation Grid.

READMISSIONS

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.

Hospital V has reported a 22% 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 conduct their own clinical assessment to look for signs and symptoms that could trigger readmissions.

o Encouraged physicians to conduct a thorough assessment prior to discharge o Adopted the Primary Nursing Model, so there is clear accountability for each patient’s care

plan o Redesigned the Medication Reconciliation and Discharge processing forms to enhance

features that 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 Involvement of Case Management in the discharge process by arranging all appointments

and conducting follow up calls 24-48 hours post discharge to check on patient condition.

WHAT WORKED:

Worked with our facilities 1x1 during taking stock visits to understand what actions they are taking to reduce readmissions and spread best practices.

Appointment facilitation - o Hospitals are making the discharge process smoother by 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 Utilizing a call center to follow up with patients about their primary care physician

appointments Prior to discharge strategies:

o Multidisciplinary Discharge Planning Rounds (6,R,S,A,Y,Z) o “Discharge Lounges”- where counseling and coordination are organized, validated and

facilitated (Z) o Teach-Back: engaging patients and having them verbalize back discharge instructions.

(6,Z,Q,R,S,A) o Piloting a multi-drug resistant organism transfer form between facilities (currently being

piloted in a hospital system and then will be discussed for community based use)

OPPORTUNITIES FOR IMPROVEMENT:

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

READMISSIONS

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.

HEN STRATEGIES TO MOVE TOWARDS A 20% REDUCTION:

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.

Sharing and Spreading: 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.

Collaboration: o Working with QIO to attack the problem across the continuum – pursue standardized

communication tools; improve skill mix in step-down settings; partner with community pharmacies and other 3rd party providers.

o Working with the Nevada Quality Assurance Appeals Division to market and penetrate hospitals with a new Patient Advocate program that identifies patients who have discharge challenges within the 24-hour appeals period. Interviews and interventions will be coordinated with the hospitals (on issues that may not meet appeals criteria, yet are still contributors to readmission) and resolve those issues prior to discharge.

o Bringing community stakeholders together to analyze the process, prioritize topics of action and work together to resolve.

o Pilot 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) that focuses on improving 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.

Encouraging and Sharing Spread Strategies –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.

HOSPITAL STRATEGIES TO REDUCE READMISSIONS:

Technology: In keeping the momentum of successfully reducing readmission rates going, Hospital 6 has plans to develop and implement an eTool by the end of 2013. eTool provides hospital staff with the most current and comprehensive list of patient education materials. The NV HEN identified this success story by analyzing our CHIA data, which we then followed up with a site visit

Appointment facilitation - o Utilizing a call center to follow up with patients about their primary care physician

appointments

READMISSIONS

o Partnering with senior centers and skilled nursing facilities to improve care transitions. o Transferring patients to long term care facilities with ICUs o Active case management o Heart failure clinic to assist patients who cannot get an appointment with their physician

within 72 hours of discharge Post-Discharge Strategies:

o Follow-up calls to patients (emphasize Pharmacy Consults as part of this strategy) 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.

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)

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ADVERSE DRUG EVENTS (ADE)

Adverse Drug Events Data Source:

Self-reported

% of PfP-Eligible Hospitals Reporting:

60% (15/25)


Overall 23% decrease from baseline (Weighted average of outcome measures)

Figure 5: Rate per 1000 insulin doses administered over the entire reporting period. In the current reporting period,

insulin rates decreased by 17% from baseline rate of 28.3 to a rate of 23.5 (Baseline=8 facilities; Current= 8 facilities).

Figure 6: Rate per warfarin dose administered over the entire reporting period. In the current reporting period, rates

decreased 13% from baseline rate of 0.026 to a rate of 0.023 (Baseline=12 facilities; Current= 11 facilities).

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ADVERSE DRUG EVENTS (ADE)

Figure 7: Rate per 1,000 narcotic doses administered over the entire reporting period. In the current reporting period,

narcotic rates decreased 29% from baseline rate of 5.5 to a rate of 3.9 (Baseline=13 facilities; Current=14 facilities).

ADDITIONAL ADE DATA:

2 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). One these facilities has not yet supplied historical data so we cannot establish a trend)


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 hydromorphine per 1000 dose of morphine and hydromorphine 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 baseline time period for each of the ADE outcome measure that capture at least 85% of the number of facilities reporting in the current reporting period. For insulin rate, the first half of 2010 was used as baseline period and a rolling 3 month average was used for the current time period (February 2013- April 2013) to calculate insulin rate. The first quarter of 2012 was used to calculate the anticoagulant baseline rate and the current reporting period for anticoagulants rates was calculated over March 2013-May 2013. For the Narcotics outcome measure, we used a baseline period of Q1 2011 and the current period of Feb 2013-April 2013. We calculated the overall rate of improvement for ADEs 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 23%.

COST SAVINGS:

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ADVERSE DRUG EVENTS (ADE) Assuming an average of $5850* saved per Narcotic related adverse event, we estimate that our self-

reporting PfP-eligible facilities saved 247 patients and had a cost savings of $1,446,679 in the current time period (Table 2). We further estimate an annual cost savings of $5,786,715 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.

SUCCESSES:

We have accomplished a 17% relative decrease from baseline for adverse drug events involving insulin with 8 facilities reporting current data (Feb-April 2013; Figure 5).

Two facilities have reached level 4 status; 5 facilities have reached level 3 We are closing the gap on Anticoagulants which shows a 13% decrease from baseline (Figure 6) –

this is the first time that this measurement showed improvement! 29% decrease in our Narcotics monitor (Figure 7). We are at participation target. Data collection for ADEs has been a struggle in most HENs in this

regard. Currently 60% of our PfP eligible network is providing data and all of our measures are currently showing some degree of improvement.

A hospital system, composed of 5 hospitals, removed Codeine from their approved Pediatric use formulary in response to new FDA warning: http://www.fda.gov/Drugs/DrugSafety/ucm313631.htm

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.

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

WHAT WORKED:

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.

Allocating Pharmacists to high-risk care areas to have more direct intervention and care planning


Warfarin (INR) data is showing a 13% decrease from baseline with 11 unique facilities reporting current data within the past rolling 3 months (Figure 6). We will continue working with our facilities to improve screening and monitoring; depletion/removal of the B-D Vacutainer blood collection tubes which showed inaccurate results, use of evidence-based protocols and move to newer pharmaceutical products with less harm potential.

A five hospital system is using a software system called EndoTool. It requires hourly finger sticks for at least 24 hours on each EndoTool patient and it is a requirement to use it if patient is hyperglycemic in the critical care areas – this has created an anomaly in the ADE Insulin denominator and we are working with them to resolve that within the metrics.

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

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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ADVERSE DRUG EVENTS (ADE) EMR or pre-printed order sets.

Encourage hospitals to collect data on Medication related events related to Readmission – pilot with a volunteer hospital will begin within 30 days

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

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.

o 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).

o 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 TO MOVE TOWARDS A 40% REDUCTION AND INCREASE THE NUMBER OF HOSPITALS REPORTING DATA:

During our “Taking Stock” site visits, we validate that our facilities have up-to-date INR protocols, blood-glucose protocols, 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.

The HEN is requesting that facilities collect data related to the correlation of readmission to medication-related cause. We are starting with a pilot hospital and then broaden out to other facilities. Bringing community stakeholders together to analyze the 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 TO MOVE TOWARDS A 40% REDUCTION:

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

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ADVERSE DRUG EVENTS (ADE) 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

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CATHETER-ASSOCIATED URINARY TRACT INFECTIONS (CAUTI)

CAUTI Data Source:

NHSN and Self-Report


80% (20/25)


Overall 13% increase (weighted average)

Figure 8: CAUTI rate per 1000 catheter days over the entire reporting period for NHSN PfP eligible facilities. In the current

reporting period, CAUTI rates increased by 15% from a baseline rate of 1.43 to a current rate of 1.65 (Baseline=12 facilities; Current= 15 facilities).

Figure 9: Catheter Utilization rate per 1000 patient days over the entire reporting period for NHSN PfP eligible facilities. In the current reporting period, Catheter Utilization rates decreased 7% from baseline of 0.40 to a current rate of 0.38

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CATHETER-ASSOCIATED URINARY TRACT INFECTIONS (CAUTI)

Figure 10: CAUTI rate per 1000 catheter days over the entire reporting period for self-reporting PfP eligible facilities. In

current reporting period, CAUTI rate increased 5% from baseline rate of 3.4 to a current rate of 3.5. (Baseline=4 facilities; Current=5 facilities)

Figure 11 Catheter Utilization rate per 1000 patient days over the entire reporting period for self-reporting PfP eligible

facilities. In the current reporting period, rates decreased 14% from baseline rate of 0.25 to a current rate of 0.21


The NV HEN has two sources of data for PfP eligible facilities: NHSN data and self-reported data. For the NHSN data, we have obtained data from February 2011 to March 2013. The CAUTI rate is calculated as the number of CAUTI events (as defined NHSN guidelines for NHSN data or as defined by the facility guidelines for self-report data) divided by 1000 catheter days. In addition to CAUTI rate, Catheter Utilization rate is also calculated. Catheter utilization rate is defined as the number of catheter days divided by the number of patient days.

For the 15 facilities reporting NHSN data, the months of Feb 2011-April 2011 were used to calculate baseline CAUTI and catheter utilization rate and the first quarter of 2013 (January 2013-March 2013) was used to calculate the CAUTI and catheter utilization rate in current time period. The NHSN cohort is showing a 15% increase in CAUTI from baseline and a decrease of 7% in catheter utilization days. Self-report data was obtained from five PfP-eligible Critical Access Facilities (CAHs). Baseline CAUTI and catheter utilization rates were calculated over the last six month of 2011 and the current CAUTI and catheter utilization rate were calculated over the second quarter of 2013. The self-report facilities are

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CATHETER-ASSOCIATED URINARY TRACT INFECTIONS (CAUTI) showing 5% increase in CAUTIs rate and 14% decrease in catheter utilization rate when compared to the

baseline period. We calculated the overall 13% increase in CAUTI rate by taking the weighted average of the results from both self-report and NHSN data.

Figure 12: CAUTI rate per 1000 catheter days from Jan 2011-Apr 2013 for non-PfP eligible facilities. In current reporting period, CAUTI rate decreased 7% from a baseline rate of 2.68 to a current rate of 2.47 (Baseline=3 facilities; Current= 6

facilities).

Figure 13: Catheter Utilization rate per 1000 patient days over the entire reporting period for non-PfP eligible facilities. In

the current reporting period, rates decreased 18% from baseline rate of 0.47 to a current rate of 0.39.


Six non-PfP eligible facilities, consisting of LTACs and Rehab hospitals, provided data through self-report. The current CAUTI rate was calculated over the 2nd quarter of 2013 (April-May 2013) and the baseline CAUTI rate was calculated over the 1st quarter of 2011. A 9% decrease in CAUTI rate and an 18% decrease in catheter utilization rates were found in the current reporting period compared to baseline.

SUCCESSES:

8 PfP facilities and 5 non-PfP facilities have achieved level 3 or 4 status. We are collaborating 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.


Encourage interventions such as criteria-based protocol approval that empowers nurses to remove catheters without a doctor’s order to further reduce Catheter Utilization. Our PfP eligible facilities are only showing single digit decreases in the Catheter Utilization Rates (Figure 9 and Figure 11).

Identifying new devices that can be used effectively in lieu of catheters, changing behaviors and increasing trust in the new methods.

Work with our hospitals to determine why the CAUTI rate is increasing. Potential theories include: o recent revised criteria (effective Jan 2013), regarding the role of fever, indicate that if the

fever is suspected to have originated from a different diagnostic source (ex. pneumonia) but any other CAUTI-related criteria exists, then the CAUTI must be reported (http://www.cdc.gov/nhsn/acute-care-hospital/index.html).

o More attention and education on the topic of CAUTI has led to better surveillance and increased reporting of CAUTIs.


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.

Dr. Eugene Chu spoke at our July 2013 Plenary to reinforce the CUSP approach to improvement


Utilize the strategies developed by NHA and QIO CUSP collaborative of Unit-Based Safety Programs. Encourage hospitals to conduct daily multi-disciplinary rounds to include assessment and actions

to remove catheter or look for signs of infection. 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.). 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 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)

CLABSI Data Source:

NHSN and Self-Reported Data


86% (19/22)

Measures Meeting 301/6/60 Goals:

NHSN Cohort, Participation: 64% (14/22), Improvement: 20%

Figure 14: CLABSI rate per 1000 central line for Self-Reported PfP eligible facilities. In current reporting period, CLABSI

rate increased 6% from a baseline rate of 1.6 to a current rate of 1.7 (Baseline=4 facilities & Current= 5 facilities)

Figure 14: CLABSI rate per 1000 central line days for NHSN PfP eligible facilities. In the current reporting period, rates

decreased 20% from baseline rate of 1.27 to a current rate of 1.01. (Baseline= 14 facilities & Current=14 facilities)

1 PfP’s goal is to reduce “preventable” harm by 40 percent. Studies have shown that 44 percent of harm is preventable. Therefore, HENs must show at

least a 40 percent reduction of 44 percent of all harms, which equals a 17.6 percent overall reduction in harms.

23

CENTRAL LINE-ASSOCIATED BLOODSTREAM INFECTIONS (CLABSI)

Figure 15: CLABSI rate per 1000 central line days from July 2010 to May 2013 for non-PfP eligible facilities. Data begins

July 2010 because before that only 1 facility was reporting from this cohort. In the current reporting period, rates decreased 28% from baseline rate of 1.4 to a current rate of 1.0. (Baseline=3 facilities; Current=5 facilities)

DATA ANALYSIS:

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 Q1 2011 and the current CLABSI rate is calculated over the last 6 months (Q4 2012 & Q1 2013). The NHSN cohort represents 64% of our PfP eligible facilities and is showing 20% improvement; therefore the NV HEN is achieving the 30/6/60 goal for this HAC (see previous page).

Five additional PfP-eligible facilities self-report CLABSI data bringing our total participation rate for the HAC up to 86%. The baseline period for self-report CLABSI rate was the first 6 months of 2011 and the current time period for the PfP-eligible self-reported data is Q2 2013. The self-report cohort is showing 6% increase in CLABSI rate.

The NV HEN also has seven non-PfP eligible facilities (LTACs & rehabs) who self-report CLABSI data. Five of these facilities have data in the current time period (2Q 2013) and the baseline period (first 6 months of 2011). The non-PfP eligible facilities are showing 28% reduction in CLABSI rates.

COST SAVINGS:

Assuming an average of $19,000* saved per event (Table 2), we estimate that our PfP-eligible facilities reporting to NHSN saved 13 patients and had a cost savings of $247,000 in the current time period. We further estimate an annual cost savings of $494,000. 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.

SUCCESSES:

2 facilities achieved level 3 status, 8 facilities achieved level 4 status and 2 facilities achieved a level 5 status on the participation grid

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CENTRAL LINE-ASSOCIATED BLOODSTREAM INFECTIONS (CLABSI) Progressive Hospital, a LTAC facility, is one of the facilities who has 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.


Although still showing a 20% decrease from baseline, our CLABSI rate increased in Q2 2013 relative to Q1 2013. We are working with our facilities to gain a better understanding for these results. One potential 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. We are monitoring and working with all our hospitals to evaluate practice patterns.

HEN STRATEGIES TO INCREASE IMPROVEMENT:

During “Taking Stock” 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 hospital strategies with their peers to move them to improve beyond their current rate.

Dr. Eugene Chu spoke at our July 2013 Plenary to reinforce the CUSP approach to improvement

HOSPITAL STRATEGIES TO INCREASE 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.

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 population as early as possible so that problem discovery and intervention attempts can begin proactively - so far four hospitals have made this commitment and data collection began on April 1.

Use 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

25

EARLY ELECTIVE DELIVERY (EED)

Early Elective Delivery Data Source:

Self-Report


75% (9/12)

% of Reduction in Harm (PfP-Eligible Hospitals)

78% Reduction

Figure 16: EED rate per deliveries of newborns that were >= 37 weeks gestation and <39 weeks gestation over the entire reporting period for PfP eligible facilities. In current reporting period, EED rate decreased 78% from a baseline rate of

9.6% to a rate of 2.1% (Baseline=8 facilities; Current=9 facilities).


The NV HEN uses self-report and previously collected Leapfrog data to calculate EED rate our PfP eligible facilities. A total of eight hospitals have provided both current and historical data. Four hospitals provided both historical and current EED data via self-report to the HEN. For the remaining 4 hospitals, historical data was generated using 2010 and 2011 Leapfrog data. 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. We projected our 2010 and 2011 benchmark numbers by multiplying the Leapfrog rates by the actual total number of mothers giving birth to babies with >37 weeks and <=39 weeks of gestation completed in 2010 and 2011. We calculate the EED rate using the 2011 average as the baseline reporting period and the current report time period is Q1 2013. Nine unique facilities reported data to us during this current report time period and showing a 78% reduction in EED.

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EARLY ELECTIVE DELIVERY (EED)

COST SAVINGS:

A study published in the American Journal of Obstetrics and Gynecology found that babies born by EED were 4.8% more likely to go to the NICU than full-term babies. The estimated the cost of NICU stay is $15,172 (Table 2). We estimate that in the current time period our facilities prevented 3 babies from being admitted to the NICU saving more than $45,516 (Table 2). We further estimate an annual cost savings of $182,064.

SUCCESSES:

78% reduction in EEDs when current time period is compared to baseline (Figure 16) 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.

7 facilities have achieved a level 3 status or higher. o Two facilities have achieved level 5 status by successfully reducing their EED rates by more

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


Continue to increase the number of hospitals reporting current and historical data. Move the rest of the hospitals to level 3 (or higher) status


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. Develop working relationship with new Strong Start Initiative in Nevada to look for synergistic

ways to advance the goals


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). A taking stock visit with one of the rural facilities to discuss hard stop and other activities are occurring August 2nd.

Make Patient Education Materials available to Patients and include in pre-natal counseling

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OBSTETRICAL ADVERSE EVENTS (OB)

OB Adverse Events Data Source:

CHIA


100% (12/12)


Overall 49% Reduction (weighted average)

Figure 17: Birth trauma resulting in injury to neonates per 1000 live births over the entire reporting period for PfP

eligible facilities. In current reporting period, the rate of birth trauma resulting in injury to neonates decreased 100% from a baseline rate of 0.16 to a rate of 0. (Baseline=12 facilities; Current=12 facilities)

Figure 18: Birth trauma: vaginal delivery with instruments per 1000 deliveries over the entire reporting period for PfP eligible facilities. In current reporting period, the rate of birth trauma: vaginal delivery with instruments decreased 15%

from a baseline rate of 150 to a rate of 128 (Baseline=12 facilities; Current=12 facilities)

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Figure 19: Birth trauma: vaginal delivery without instruments per 1000 deliveries over the entire reporting period for PfP

eligible facilities. In current reporting period, the rate of birth trauma: vaginal delivery without instruments decreased 32% from a baseline rate of 26 to a rate of 17 (Baseline=12 facilities; Current=12 facilities)


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. 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.

COST SAVINGS:

Assuming a $3000 cost for an adverse OB event (AHQR), 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.

SUCCESSES:

A 100% decrease from baseline for injuries to neonates (Figure 17) A 15% decrease from baseline for vaginal deliveries with instruments (Figure 18) A 32% decrease from baseline for vaginal deliveries without instruments (Figure 19) 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 personnel who is master trainer in Advanced Life Support in Obstetrics and is working on training emergency responders in Life Support for Obstetrics.

29


WHAT WORKED:

The hospitals conduct periodic drills for OB emergencies that could result in injury – training facilitation via UNSOM project and HEN best-practice examples

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

The trained staff facilitate the spread within their own organization as well as between organizations

Hospitals participate in OB Advisory Committee to share best practices Informed our hospitals of webinars such as Pacing Events, IHI and March of Dimes events


Continue to reduce the rates of birth trauma with and without instruments and sustain low rates of injury to neonates.

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.


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 Advanced Life Support in Obstetrics (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)


The hospitals are continuing to run drills for OB emergencies and bringing more information about low-cost methods to run simulations to our facilities.

Increase patient education and engagement Pitocin Protocol reviews Advancing availability of Mid-Wives Shoulder dystocia Protocols Established a Hemorrhagic Response Emergency Cart

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FALLS WITH SIGNIFICANT INJURY

Falls with Significant Injury Data Source:

CHIA and Self-Report


96% (24/25)


Overall 43% Reduction (weighted average)

Figure 20: 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).

Figure 21: Falls trauma rate per 1000 patient discharges over the entire reporting period for non-PfP eligible facilities. In

current reporting period, the rate of falls trauma rate decreased 100% from a baseline rate of 3.10 to a rate of 0.00 (Baseline=6 facilities; Current=5 facilities).

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FALLS WITH SIGNIFICANT INJURY

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).

DATA ANALYSIS:

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 and therefore directly correlate 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 rate was calculated using the first 6 months of 2010 and the current fall trauma rate was calculated using Q1 2013 (Figure 20). 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 had 5 facilities reporting via CHIA. Baseline period was the 2010 average and the current reporting period was defined as Q1 2013. There were no traumas from falls reported by the cohort of 4 non-PfP eligible facilities reporting into CHIA during Q1 2013. Overall we continue to see reduction in falls trauma rate across both PfP and non-PfP eligible facilities.

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.

SUCCESSES:

21 facilities achieved level 3 status or 4 status

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FALLS WITH SIGNIFICANT INJURY 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 and shared their best practice within the HEN and through NCD.

WHAT WORKED:

Utilizing Patient Assessment Teams to determine patients at risk for falls Making ALL staff responsible for falls prevention Falls prevention signage and garments Engaging patient and family in falls awareness and post falls huddles Utilizing root cause analysis following an incident Utilizing bed alarms and assistive devices Scheduled toileting for at-risk patients Indicating lift/transfer requirements on white boards and or signage Post Fall Huddles Certified Nursing Assistant (CAN) Champions Sitters for high-risk patients


The most challenging area is the geri-psych population. 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


Even though our data collection measures and tracks the high-harm events – our interventions are centered around all cause-all harm strategies. During our “Taking Stock” visits, we have validated that our facilities have a multi-pronged approach to falls prevention, which includes increased staff coverage during fall risk periods; scheduled toileting; falls assessment and I.D.; alarms and other electronic monitoring; sitters and patient/family engagement, etc.

We partner the mentor hospitals with the others to share best practices 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 specialized “Falls” training to struggling facilities - this is an evidence-based

program that is offered free of charge We share information from Pacing Events, national toolkits and success stories (the monthly calls,

monthly newsletter, and educational sessions). 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.


Mentor hospitals will share strategies for improvement with other hospitals

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FALLS WITH SIGNIFICANT INJURY Patient-Family Engagement strategies geared to partner in prevention

Utilize root cause analysis (RCA) for fall events. (RCA training was offered in May 7th & 20th 2013) Relate Falls to Medication use (pre-assessment for Risk and Follow-up as RCA)

34

PRESSURE ULCERS

Pressure Ulcers Data Source:



92% (23/25)


12% Increase

Figure 22: Pressure ulcer rate per 1000 eligible discharges 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)

Figure 23: Pressure ulcer rate per 1000 eligible discharges 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)

35

PRESSURE ULCERS


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 one PfP eligible facility that is not included in the CHIA database. This facility is not included in the overall HAC improvement rate since we have not obtained benchmark data from this facility.

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.

Overall, although we see a slight increase in pressure ulcer rate at the reporting PfP facilities, we believe that they continue to address this HAC as a priority and we are confident that the PfP facilities will show improvement as have the non-PfP eligible facilities.

SUCCESSES:

23 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 – their strategies have been shared within the HEN and with the NCD.

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 23)

WHAT WORKED:

Utilizing Patient Assessment Teams to determine patients at risk for pressure ulcers Making ALL staff responsible for pressure ulcer prevention, implementation of increased skin

assessment on hourly rounding. Use of Med-Line Pressure Ulcer measurement tool (or other similar assessment tool) Engaging patient and family in pressure ulcer awareness and provide patient engagement

education in verbal and written forms. Improved coding and identification of Pressure Ulcers vs. various other skin conditions. Utilizing root cause analysis following an incident Establish Products Review Committees that look for prevention options and pilot new techniques Upgrade equipment with adequate accessibility and staff training: Specialty beds, moisture

barriers, pressure point buffers, proper nutrition Program enhancement through education and increasing awareness with development of Pressure

Ulcer Advisory Committees in northern and southern Nevada.


Increase awareness of best practice in wound preventions and care through advisory committees and educational seminars. This topic will continue to be prioritized by the HEN to move toward the 40% improvement goal.

Encourage facilities to enhance patient/family engagement through additional education. Encourage facilities to continue to educate on proper coding and documentation of wounds.

36

PRESSURE ULCERS


Pressure Ulcer Advisory Team (Wound Nurses, Nutritionists, Physical Therapists) meet monthly to share best practices and toolkits that they will bring back to their facilities for implementation.

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.

Introduced “Bed Mapping” and Movin-ez, patient movement monitoring device as Best Practice strategies: From our collaboration with the Northern Nevada Pressure Ulcer Advisory Committee, we learned of a device that can be clipped onto the patient and will collect patient 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. We see this as a potential tool for staff to augment Pressure Ulcer (PU) prevention and documentation.

The Southern Advisory Team identified the use of the MedLine NE1 tool – which is being spread throughout the HEN as a potential best-practice to provide a standardized and simplified approach to wound assessment and documentation.

Share the Prevena Incision Management System (portable, disposable wound vacuum device) technology with facilities to possibly assist in the treatment of Pressure Ulcers.

We partner the mentor hospitals with the others to share best practices We 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) We share information from Pacing Events, toolkits and success stories via newsletter, monthly call

and education sessions. Training the facilities to look for the signs of Deep Tissue Injury and to LOOK BACK 24-72 hours to

try and find the causative event and location. Providing information on new prevention product lines for devices (i.e. silicon) and wound healing. Encouraged collaboration and sharing of best practices between facilities during networking

sessions of plenary sessions.


Mentor hospitals will share strategies for improvement with other hospitals Implement new tools and activities to assess and prevent pressure ulcers Increase education of staff to ensure proper coding and wound identification Utilize root cause analysis for events Patient-Family Engagement strategies geared to partner in prevention Implementation of improved documentation in EMR for prevention of miscoding

37

SURGICAL SITE INFECTIONS (SSI)

SSI Data Source:

NHSN and Self-Report


89% (17/19)

Measures Meeting 30/6/60 Goals:

NHSN COLO cohort, Participation: 79% (15/19), Improvement: 50%

Figure 24: 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 50% from a baseline rate of 0.04 to a rate of 0.02. (Baseline=15 facilities; Current=15 facilities)

Figure 25: 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 increased 18%

from a baseline rate of 0.005 to a rate of 0.006 (Baseline=12 facilities; Current=12 facilities)

38


Figure 26: 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)


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 that are self-reported to us from some of our facilities. 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 was Q1 2013 and the current time period for the SSI rate from HYST procedures was Q1 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 which represents 79% of our PfP eligible facilities, so we are using this cohort to meet our 30/6/60 goals. The NHSN cohort has a achieved a 50% SSI rate reduction comparing the current time period to baseline.

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. Our SSI from HYST is still showing an increase from baseline (18%), our Nevada HEN facilities are actually doing quite well in this measure. During the baseline time period, only three SSIs from hysterectomies were reported from a total of 12 hospitals within our HEN. During Q1 2013 there were only 3 SSIs for 472 Hysterectomies. This rate is extremely low when compared to published research on the AHRQ website that estimates between 2% and 13% of patients experience an SSI following a hysterectomy*. Using these estimates, we would expect our 12 HEN facilities to have had between 9 and 62 SSIs during Q1 2013. During this current quarter, our 12 HEN facilities collectively only reported 3 SSIs from hysterectomies, therefore it seems that the NV HEN facilities reporting data to NHSN are doing quite well. Our goal is to eliminate SSIs in all procedures by spreading of best practices from hysterectomies surgeries to the other types of surgery within our facilities. This strategy has been successful.

*Australian Council on Healthcare Standards (ACHS). ACHS clinical indicator users' manual 2012. ULTIMO NSW: Australian Council on Healthcare Standards (ACHS); 2012 Jan. various p.

39


COST SAVINGS:

In the most recent 3 months, our data indicates that the hard work of our facilities resulted in an avoidance of 8 potential SSI associated with Colon Surgery at an estimated cost savings of $20,000 per event*, projecting an annual cost savings of $640,000 (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

SUCCESESS:

COLO SSI RATE from facilities reporting in NHSN - 15 facilities, 50% decrease from baseline (Figure 24)

Self-Report - [All SSI]/[All Surgeries], 5 facilities, 50% decrease from baseline (Figure 26) Two Facilities committed to SUSP Cohort 2 (Q & 9) and are now are in the data reporting phase. We

expect to be able to recruit additional facilities for the next SUSP Cohort 4. 12 facilities achieved level 3 status or higher


Enroll more hospitals in future SUSP Cohorts. Promote spread of effective infection prevention strategies between facilities and between surgical

departments within facilities.


Share best practices and toolkits that they will bring back to their facilities for implementation. Our Antibiotic Stewardship/HAI Steering Committee met in July 2013 and 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.

We partner the mentor hospitals with the others to share best practices. We provide additional 1:1 assistance as needed to facilitate Incident Investigation and Root Cause

Analysis for SSI events to identify causes and solutions to mitigate future high-harm events – training conducted May 2013.

We share information from Pacing Events, toolkits and success stories via newsletter, monthly call and education sessions.

Partnership with the Nevada Division of Health to conduct training during July 2013 conference on infection prevention. – primary focus was Multi-Drug Resistant Organisms prevention and treatment strategies.


The HEN is sponsoring two hospitals in the SUSP project (Cohort 2) that are now engaged in NHSN data upload to SUSP.

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

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Two additional hospitals have expressed interest in joining a later SUSP Cohort – we are working with them to reach a final decision to enroll in Cohort 4.

Exclusive use of Chlorhexadine; Silver impregnated dressings; MRSA Decolonization; SCIP Disinfection-robotics – Xenex - terminal clean suites

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VENTILATOR ASSOCIATED PNEUMONIA/ EVENT (VAP/VAE)

VAP/VAE Data Source:


% of Hospitals Reporting:

95% (19/20)


Overall 55% decrease from baseline

Figure 27: 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)

Figure 28: 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)

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Figure 29: 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)


For the VAP rate, we received self-reported data and CHIA data from our facilities. 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) in 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.

For non-PfP eligible facilities, the VAP rate was calculated over a baseline period of the first half of 2010 and the current reporting period of the first quarter 2013. The non-PfP eligible facilities are not included in the overall percent improvement per HAC.

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)

SUCCESSES:

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. They also implement sedation vacation for ventilator

43


patients every morning.

WHAT WORKED:

Use of toolkits and bundles Validated that all HEN facilities are aware of and understand the new VAE criteria Utilizing root cause analysis following a true VAE incident (RCA training May 2013) Team participation and rounding – nursing, respiratory therapists, dieticians, physicians, etc., to

assess and execute weaning and infection surveillance


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 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.


Share best practices and toolkits that they will bring back to their facilities for implementation. Partner the mentor hospitals with the others to share best practices. Provide additional 1:1 assistance as needed to facilitate root cause analysis 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 educational 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.

Once the VAE data posts from NHSN, we will analyze it as compared to the previous VAP data – decide and justify whether to roll up the data together.


Mentor hospitals will share strategies for improvement with other hospitals. Implement new tools and activities to prevent VAP. 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

Daily rounds to assess ventilator pathway and utilization Encourage ventilator “vacations”.

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VENOUS THROMBO EMBOLISM (VTE)

VTE Data Source:

(Data Source) CHIA


88% (22/25)


24% Reduction

Figure 30: 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)

Figure 31: 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)

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DATA ANALYSIS:

We calculate the VTE rate by querying pulmonary embolisms (PE) and deep vein thrombosis (DVT) from the CHIA database. 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.

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

SUCCESSES:

88% data participation 9 facilities achieved level 3 and 8 of our facilities achieved level 4 status 24% decrease from baseline PfP eligible facilities (3% better than Q4 2012 (Figure 30) 65% decrease from baseline non-PfP eligible facilities 2010 average to Q1 2013 average (Figure 31)

WHAT WORKED:

Use of toolkits, order sets and bundles AHRQ VTE Tool-Kit shared with membership Utilizing root cause analysis following an incident Proper anticoagulation assessment that balance risk/benefit for patient Multi-pronged interventions: pharmaceutical and non-pharmaceutical Treatment pathway guided by patient risk assessment Criteria based order sets and electronic medical records (EMR) prompts Develop and distribute patient/family education regarding VTE risks and preventions


Encourage additional facilities to enhance program to rise to level 3 status Continue assessment of facilities for implementation of strategies to all patients, not just surgical Engaging patient and family in VTE awareness, provide patient engagement education in verbal and

written forms. Use pre-printed order sets and EMR checks and balances that reflect best practice.


We partner the mentor hospitals with the others to share best practices Provide VTE Risk Stratification guidelines to be incorporated into paper or electronic order sets 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

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

46


Provide additional 1:1 assistance as needed to facilitate RCA for VTE events to identify causes and solutions to mitigate future high-harm events. (RCA Training was presented May 7th and 20th)

Share information from Pacing Events, toolkits and success stories via newsletter, monthly call and education sessions.

Establish VTE Advisory Committee of appropriate stakeholders to share Best Practice strategies. Facilitated collaboration at plenary sessions to share best practices of high achieving facilities.


Intake assessments and use of best-practice bundles Multi-disciplinary Team Rounding and re-assessment on a regular basis Mentor hospitals will share strategies for improvement with other hospitals Implement new tools and activities to prevent VTE Utilize root cause analysis for events Patient-Family Engagement strategies geared to partner in prevention of VTE during hospitalization and post discharge Progress toward increased use of mechanical interventions

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PATIENT AND FAMILY ENGAGEMENT

Patient and Family Engagement Report Method:

Self-Report via Taking Stock Interviews

SUCCESSES:

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 (5 PfP HEN hospitals in Southern Nevada); 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. Southern Hills CEO presented their development and criteria for forming a PFE advisory committee

to his peers at an American College of Healthcare Executives meeting. Cleveland Clinic presented their PFE implementation plan at our July 2013 Plenary Session; 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

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 July 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

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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.

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.

WHAT WORKED:

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 Collaboration with other groups to partner in this effort


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. Continue to expand our visibility, interaction and contact base within the community. Directly engage more patients in the efforts and offerings of the HENs and information on Patient-

Family Engagement


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

49


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. Marissa Brown and Terry Woolery will attend the next NICHE (Nurses Improving Care for Health-

system Elders) meeting in August.


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 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

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LEADERSHIP ENGAGEMENT

Leadership Engagement Report Method:

Self-Report via Taking Stock Interviews

SUCCESSES:

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).

WHAT WORKED:

Daily patient rounding by senior leadership, department directors and managers Utilizing a true “team” approach to quality improvement with interaction across all levels. Engaging patient and family in quality improvement efforts Leveraging the competitive nature of the market to inspire action


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.

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 will partner the mentor hospitals with the others to share best practices 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. Provide a nationally recognized speaker (Dr. Timothy McDonald) to the NHA Annual meeting – Sept

2013

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LEADERSHIP ENGAGEMENT


Mentor hospitals will share strategies for improvement with other hospitals Patient-Family Engagement strategies geared to partner in prevention 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)

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FORWARD LOOK FOR THE NEXT 30 DAYS

“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 (August topic: (tentative) Readmission).

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.

Attend NICHE conference to enhance efforts for promoting Patient and Family Engagement. Coordinate the next learning sessions of the UNSOM-NV HEN sub-contract to provide

TeamSTEPPS training in Advanced Life Support for Obstetrics (ALSO) and Team Care OB (scheduled for August 2013).

Continue SUSP program and associated NHSN data entry – possible recruitment of other hospitals in an upcoming cohort.

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: JULY 1-31, 2013: $113,824

BALANCE-TO-DATE: $532,304

ATTACHMENTS**:

1. List of Hospitals and Participation Table

2. Data display tables and aggregate graphs for Outcome and Process measures

3. HEN Aggregate dashboard template

4. Testimonial – Southern Hills Hospital and Medical Center

5. Cost FILE summary

6. HSAG August Assessment Template Analysis

** 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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