Georgia Hospital Engagement Network
Patient and Family Centered Safe Care
Putting Patients First
40/20 by ‘13
2013
The Time is Now!
Partnership for Patients Campaign
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Executive Engagement –
Executive Quality Action Council
Purpose:
Provide guidance and support to the GHA Hospital Engagement
Network on its goal of improving patient safety through
implementation of the eliminating “all cause harm” approach and
patient and family centered safe care.
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Executive Action Quality Council Members
Co-Chairs Jim Davis, CEO, University Hospital and Sheila Bennett, Floyd Medical Center
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David Andrews, Patient Advocate,
Georgia Regents University
Susan Bowen, Shepherd Center
Melody Brown, Dodge County
Hospital
Montez Carter, Good Samaritan
Hospital
Nicole Franks, MD, Emory University
Hospital Midtown
Freya Gilbert, Hughston Hospital
Babs Hargett, Emory Healthcare
Michael Hester, Optim Medical CenterJenkins
Angie King, St. Francis Hospital
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Mindy McStott, Tift Regional
Medical Center
Norma Jean Morgan, Effingham
Health System
Heidi Nelson, University Hospital
Teri Newsome, Habersham Medical
Center
Mary Pizzino, Effingham Health
System
Tina Thomas, Ty Cobb Regional
Medical Center
Brad Trower, Optim Medical CenterJenkins
Jerry West, Houston Medical Center
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Executive Quality Action Council
Vision: All Georgia hospitals will be a patient and family centered safe
care organization.
Mission: Provide leadership to the Georgia Hospital Engagement
Network to reduce all cause harm among Georgia hospitals.
Goals:
• Address Aims: Better Health; Better Outcomes; Lower Cost
• Assisting hospitals to meet the CMS Partnership for Patients goal of
reducing readmissions 20% and hospital acquired conditions 40% by
the end of 2013.
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Executive Quality Action Council
Objectives:
• Foster the support of the hospitals’ C Suite and Board to engage all
staff, including but not limited to, senior leaders, frontline staff and
physicians, as well as patient and family representatives in the
implementation of the patient and family safe care framework.
• Provide insight on realistic approaches to implement enlightened
executive leadership guide
• Provide executive guide for implementation of selected best practices
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All Cause Harm Global Tools
To Meet Goals Have to Focus on Patient Safety Culture
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Leadership
– Evidence – based Leadership
– Rounding: Executive Leaders
Engagement and Process Design Tools:
– Comprehensive Unit Safety Program (CUSP)
– Rounding: Managers and Staff
– Reliable System Process Design
– Lean/Six Sigma
Communication and Team Work
– TeamSTEPPS
Patient and Family Centered Care/Engagement
– The Healthcare and Patient Partnership Institute (H2Pi): The Patients as
Partners Training Guide http://h2pi.org/
– Partnership for Women and Families
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Patient/Family Centered Safe Care
• Advisory Action Group
• Partnerships
– National Partnership for Women and Family
– Healthcare and Patients Partnership Institute
Ask
Listen
Evaluate
Respond
Test
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Cohorts/Hospital Visits/Calls
• Every hospital has a GHA liaison
• Face-to-face hospital visit by liaison
• Why Create Cohorts
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All Teach, All Learn concept
Coaching available
Achieve rapid change
Small groups
Promotes networking
More one-on-one assistance when needed
Mentoring encouraged
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Cohorts/Hospital Visits/Calls
• Monthly Cohort calls – attendance required for recognition points
• Cohort 1: Joyce Reid (1a) , Kathy McGowan (1b), Lorna Martin (1c)
- 1st Wednesday 11:30 a.m. – 12:15 p.m.
• Cohort 2: Denise Flook (2)
– 2nd Wednesday 11:30 a.m. – 12:15 p.m.
• Cohort 3: Tracy Rutland (3)
– 3rd Wednesday 11:30 a.m. – 12:15 p.m.
• Cohort 4: Lynne Hall (4)
– 4th Wednesday 11:30 a.m. – 12:15 p.m.
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Cohorts/Hospital Visits/Calls
• Format of monthly cohort calls
– Discussion based on data
– Offers & Requests
• What do you need to be successful?
• What do you bring to the table?
– Requests from Partnership for Patients & CMS
• Time for Implementation
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Cohorts/Hospital Visits/Calls
• Hospital visits – opportunity to share & showcase
• Review data – Organizational Assessment Tool, HAC,
Readmission, Core Measure, etc.
• What keeps you up at night?
• Resources
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Specific Topic Affinity Webinars*:
All Teach, All Learn
• GHA will offer monthly Affinity Group calls on Wednesdays
from 11:00 a.m. – 11:30 a.m. (See Calendar)
– First Wednesday:
– Second Wednesday:
– Third Wednesday:
– Fourth Wednesday:
Reducing Readmissions*
Hospital Acquired Infections (HAI)
Hospital Acquired
Conditions/Events (HACs)
OB Adverse Events
• CMS national calls – will be notified of date & time
– *February 11 – Patient & Family Engagement 3:00 p.m. – 4:30 p.m.
– *March 4 – Readmissions 3:00 p.m. – 4:30 p.m. (will replace March 6
Readmission call)
– *April 1 – Adverse Drug Events 3:00 - 4:00 pm
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Extra credit for recognition
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Regional Meetings
• Combine cohorts
• All Teach, All Learn
• Dates
– May & August
– November – Year End Celebration
• Geographic locations
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Albany
Athens
Dalton
Macon
Marietta
Waycross
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Small/Rural CAH Approach
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Umbrella of Quality Improvement
Taking down the silos – building new relationships
Expanding our horizons
Promoting our culture of safety
Learning from each other
Rural Affinity Change Package
Fine-tuning our strategies
Hard stop for discharge program
Celebrating as we go!
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Calendar of Events
• You Asked For It!
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Organizational Assessment Tool
• Assessment:
– Some questions confusing
– Terminology needs clarification on some questions
– Tool more sensible when read currently compared to a year ago when
the HEN was just beginning to launch and some of the content was new
– Data reports and analysis seem premature since this is baseline data
– National Content Developer (NCD) listened to our feedback
• Currently revising the OAT
• New version available in the Spring
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Organizational Assessment Tool
• Recommendations:
– Conduct a mandatory conference call for HEN leaders
– Prior to conference call, send electronic .pdf version of the OAT survey
to all members and set the expectation that they read for clarity
– During the conference call, identify additional items that require
clarification in addition to the questions listed above
– Ask GHA staff to compile a data dictionary for these questions and
terms based on our GHA HEN leaders and then circulate the document
– Launch “wave two” of the survey in Spring 2013 with the intent to
evaluate where we have progressed with the guidance of the HEN
activities
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Organizational Assessment Tool
• Recommendations continued
– Communicate effectively that the OAT survey should not be used with
the intent to compete with one another but as a personal tool for each
organization to identify if their actions are producing the gain that is
expected.
– Subsequent reports should feature “wave one” survey as the baseline
and “wave two” as effect of change.
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Upcoming Educational Opportunities
2013 Statewide In-Person Meetings
(attendance required for Recognition Program)
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February 12-13
June 5-7
July 9-12
August 7-9
GHA Annual Meeting
Nurse Leadership Institute
GHA Summer Meeting
Center for Rural Health
Lean Six Sigma Green Belt Training
• June 17-21, GHA Education Center
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Partnership for Patients (PfP) National Calls
• Strategies for Advancing Patient and Family Engagement
as a Change Engine
– Monday, February 11, 2013 3:00 p.m.- 4:30 p.m.
– To register go to:
http://www.visualwebcaster.com/event.asp?id=91854
• All Cause Harm Across the Board/Readmission
– Monday, March 4, 2013 3:00 p.m.- 4:30 p.m.
• Adverse Drug Events
– Monday, April 1, 2013
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3:00 p.m.- 4:00 p.m
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Data Requirements
• Outcomes
– Most HACs and Readmission data from other sources so no further
submission needed
– HAIs (CLABSI, CAUTI, SSI (colon surgeries) and VAE) – must confer
rights to NHSN data to GHA, monthly data
– EED data submitted monthly
– ADE data
• Process Measure Data
– Quarterly Best Practices Attestation online survey
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2013 Proposed Recognition Program
The GA HEN Recognition scores are calculated based on the
following dimensions:
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Participation (15%)
– In Person Meetings
– Cohort Meetings
– Regional Meetings
Completion of Evaluations for any HEN Meeting (10%)
Submissions (25%)
– Completion of the Organizational Assessment Tool in Spring 2013
– Quarterly Best Practices Attestation Survey
– Submission of outcomes data as required (EED, NHSN, ADE, Core Measures)
Achieving the HEN Targets (50%)
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Recognition Program
Participation scores are calculated as a percentage of attendance in
required HEN Meetings.
• In Person Meetings:
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Patient Safety Summit (January 9 - 10, 2013)
Trustee Meeting (January 11 - 13, 2013)
February Kick Off (February 7, 2013)
GHA Annual Meeting (February 12 - 13, 2013)
Nurse Leadership Institute (June 5 - 7, 2013)
GHA Summer Meeting (July 9-12, 2013) OR Center for Rural Health
Meeting (August 7-9, 2013)
– Regional Cohort Meetings held in various Georgia regions in May,
August, and November
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Recognition Program
• Cohort Meeting Dates:
Cohort 1
Cohort 2
Cohort 3
Cohort 4
3/6/2013
3/13/2013
3/20/2013
3/27/2013
4/3/2013
4/10/2013
4/17/2013
4/24/2013
6/5/2013
6/12/2013
6/19/2013
6/26/2013
7/3/2013
7/10/2013
7/17/2013
7/24/2013
9/4/2013
9/11/2013
9/18/2013
9/25/2013
10/2/2013
10/9/2013
10/16/2013
10/23/2013
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Recognition Program
The following data sources are used:
– Georgia Discharge Database: used in the calculation of Hospital
Acquired Conditions and Patient Safety Indicators
– Readmissions Data: We have partnered with the Georgia Medical Care
Foundation to obtain overall 30-day Readmissions data.
– Early Elective Deliveries: This data is directly reported to us by the
hospitals.
– National Healthcare Safety Network (NHSN): Used for CAUTI,
CLABSI, SSI and VAE
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Recognition Program
Measure
Data Source
Target
Weight
CAUTI Rate per 1000 Catheter Days
NHSN
1.3
5
CLABSI Rate per 1000 Device Days
NHSN
1.1
5
SSI, Colon Surgery Rate per 100
Procedures
NHSN
1.7
5
5% of
Patients
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CMS HAC
0.29
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AHRQ
0.47
5
Postoperative PE or DVT Rate per
1000 discharges
AHRQ
4.05
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EED-PC 01 (Rate)
TJC
5%
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Reducing Readmissions (Rate)
Medicare PPS
15.24%
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ADE- INR>5
Hospital Reported
Falls and Trauma Rate per 1000
discharges
Pressure Ulcer Rate per 1000
discharges
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Recognition Program
• Extra Credit points are awarded for:
– Participation in Affinity Group educational calls
– Achieving 4’s and 5’s by CMS rating scale
– Meeting the CMS Patient and Family Engagement Requirements;
defined on the Attestation document
– Presentations in GHA and CMS meetings
– Participation in the SUSP Program
• Maximum extra credit points = 10
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Recognition Program
Three categories of Exemplar hospitals are identified based on
overall Recognition Scores:
– Elite Circle: Hospitals who achieve 90th percentile rank
– Chairman’s Circle: Hospitals who achieve 80th percentile rank
– Presidential Circle: Hospitals who achieve 70th percentile rank
Ideal Hospital: Achieving CMS ranking of 4 or 5 in six or more
HACs
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We Look Forward to Working
With You in 2013!
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Contact Information
• Phone: 770-249-4500
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Vi Naylor: vnaylor@gha.org
Kathy McGowan: kmcgowan@gha.org
Joyce Reid: jreid@gha.org
Denise Flook: dflook@gha.org
Faizah Muheb: fmuheb@gha.org
Martha Harrell: mharrell@gha.org
Lynne Hall: lhall@gha.org
Lorna Martin: lmartin@gha.org
Tracy Rutland: trutland@gha.org
Michelle Sprouse: msprouse@gha.org
Shearl Lesser: slesser@gha.org
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