2014 K-HEN
Commitments
Title Block
Elizabeth Cobb
Donna Meador
Dolores Hagan
Welcome!
Thank you so much for your support
throughout this project so far, and
for helping us gain approval for
continuing in 2014!
Agenda
1. Discussion of Commitments for 2014:
a. Data Submission Requirements in the 10/11
clinical focus areas
b. Continued work on Patient & Family
Engagement, Leadership, Teamwork, and
Communication, and Measurement
c. Add/begin component of Health Care Disparities
2. Incentives to continue:
a. Data Submission Incentive (quarterly)
b. Improvement Incentive (mid-year and at end of
project)
Agenda, continued
c. Harm Across the Board Incentive
-(replacing monthly progress report)
3. Education and Activities Planned
for 2014
4. Improvement Leader Fellowship
changes for 2014
5. Q & A, Feedback
1. Commitments for 2014
Data Submission Requirements:
- all applicable topic areas
- standardized (aligned) measures for
each topic – we will prescribe a minimum
submission requirement & a higher level for increased
incentive
- data submission schedule
- data submission tool will be coming outAll 2014 data will be submitted directly to K-
Measures by Area
Adverse Event
Area (AEA)
Measures
Adverse Drug
Events (ADE)
• Excessive anticoagulation (EOM-12)
• Glucose control (EOM-13)
• Opioid safety (EOM-111)
• An overall measure of ADEs*
Falls
• Falls with or without Injury (EOM-37)
• Falls with injury (minor or greater) (EOM-38)
Pressure Ulcer
• Stage II or Greater hospital acquired (EOM-58)
• Stage III or IV greater subset (AHRQ PSI 3) (EOM-61)
VTE
• Post-op PE or DVT (AHRQ PSI 12) (EOM-105)
• Potentially preventable VTE (EOM-104)
EED
• Early Elective Delivery (JC PC-01) (EOM-40)
AEA
Measures
Other OB
• Birth Trauma Rate – Injury to Neonate (AHRQ PSI 17) (EOM48)
• OB Trauma rate-vaginal delivery with instrument (AHRQ 18)
(EOM-54)
• Birth Trauma Rate-vaginal delivery without instrument (AHRQ
19) (EOM-55)
• OB Hemorrhage*
• Preeclampsia treatment and management to prevent morbidity
and mortality*
Readmissions
• Diagnosis specific 30-Day readmission rate
• AMI (EOM-76); Heart Failure (EOM-77); Pneumonia
(EOM-78)
• 30-Day All Cause readmission rate (EOM-75)
AEA
Measures
CAUTI
• CAUTI Rate (NHSN/NDNQI) – ICU only (EOM-19)
• CAUTI Rate (NHSN/NDNQI) – All Units (EOM-18)
• Catheter utilization ratio (catheter days/patient days) (EOM-21d)
• ED Catheterization rate*
CLABSI
• CLABSI rate (NHSN/NDNQI) ICU only (EOM-25)
• CLABSI rate (NHSN/NDNQI) All Units (EOM-24)
• Days Since Last CLABSI*
SSI
• Surgical site infection rate (NHSN) for colon and abdominal
hysterectomy procedures within 30 days of procedure(EOM-89)
• Surgical site infection rate (NHSN) for four or more procedures
within 30 days of procedure**
VAE/VAP
• VAC (NHSN) (EOM-96a or EOM-96d)
• IVAC (NHSN) (EOM-96b or EOM-96e)
• Possible/Probable VAP (NHSN) (EOM-96c or EOM-96f)
Incentive Requirements
• Both minimum and full participation require
timely data submission
– Data is due at the end of the month for the
previous month (exceptions: Readmissions
and SSI)
– Full participation requires either submission or
attestation that at least one corresponding
process is being collected
Commitments cont’d.
Continued work on Patient and Family
Engagement and Leadership– we will
continue to submit data to HRET on 5 elements of PFE
and 4 elements of Leadership; we will continue to offer
education and resources related to patient safety,
teamwork, and communication; we will continue to
work with hospitals on data/measurement/reporting
Add/begin HealthCare Disparities
Component - for now this will consist of 2 surveys
throughout the year from HRET for each hospital
2014 Incentive Structure
2014 Funding for all of the HENs based on
data submission and improvement
structure –
• We will be implementing a 2-tiered quarterly
bonus/incentive strategy based on completing
minimum and maximum requirements
• Mid-year and end-of-project bonus/incentive
based on improvement levels
Incentive Structure cont’d.
• Monthly progress reports will now be
submitted as “Harm Across the Board”
reports – moving from focus on single
harm to harm across the board – we will
incentivize hospitals who submit at least
one HAB report each qtr.
(we will provide more info on the HAB
report later)
2014 Education and Activities
K-HEN:
1. Coaching Calls monthly and bi-monthly depending on
topic
2. Site Visits to all hospitals
3. Annual KHA/K-HEN Quality Conference 3/18-19
4. TeamSTEPPS webinars and workshops
5. Patient Safety Hero Awards
6. OB Advisory Committee Meetings
7. Periodic focused meetings, such as K-HEN or HRET
staff meeting with local community coalitions
2014 Educ. & Activities cont’d
8. Sponsorships to national meetings –
AHA Rural Conference, NAHQ, IHI, NPSF
Congress, AHA Quality and Safety Roadmap,
etc.
9. Regional Meetings
10. Other Suggestions/Needs?
11. Improvement Leader Fellowship
education and activities (next slide)
2014 Educ. & Activities cont’d
HRET:
1. Updated Change Packages - each topic
2. 2-3 day Boot Camps dedicated to data,
OB, Readmissions, ADE, C-Diff, and
Sepsis; each will be repeated during the
same week
3. ILF program with in-person meetings &
monthly live-streamed meetings
4. Other events in process
2014 Improvement Leader Fellowship
Great program in 2012 and 2013 –
changes to design make more beneficial
to hospitals
• Currently 1200+ fellows (8 in KY)
• 27 ILF meetings held, 533 registered for IHI Open School
• Feedback from fellows has been very positive
2014 – Junior, Senior, and Champion levels
Goal – build skills in improvement in SHA and HEN
hospital quality leaders through continuous learning &
coaching on improvement methods & tools as applied
to the Partnership for Patients content areas.
2014 Improvement Leader Fellowship
2014 Plans:
1. In-Person Regional Meetings
– 22 meetings March-November
- on-site meetings specifically designed to
combine clinical knowledge with improvement
techniques, ½ day in length, for networking &
shared learning, at State Hosp. Assoc. offices
(KHA?)
2. Monthly live-streamed meetings, 1-3 CT every
third or fourth Wednesday of the month
2014 Improvement Leader Fellowship
Fellowship education led by IHI Faculty
Attendance requirements – 1 in-person
meeting, 8 of 10 virtual meetings
HAB completion
Pre-work assignments
Specific assignments for each level
*Secondary goals for KY – build improvement capacity
for ongoing quality work, foster systems thinking
knowledge, keep the enthusiasm going!
Questions?
Feedback?
Thank you!