HEN 2.0 and The IHA Institute
Road Ahead
IMPROVING PATIENT SAFETY ACROSS ILLINOIS
May 5, 2015
IHA Institute HEN Team
Jay D. Bhatt, DO, MPH, MPA, FACP
Chief Health Officer, Illinois Hospital Association
Cathy N. Grossi, JD, BSN, CPHQ
Vice President, Institute for Innovations in Care and Quality
Helga Brake, PharmD, CPHQ, CPPS
Senior Director, Institute for Innovations in Care and Quality
Marchelle Djordjevic, MBA, CPHQ
Director, Institute for Innovations in Care and Quality
Adam Kohlrus, MS, CPHQ, CPPS
Director, Institute for Innovations in Care and Quality
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IHA Institute HEN Team
The HEN wouldn’t cluck without support from our amazing
administrative staff!
Marsha Curtis
Manager, Institute for Innovations in Care and Quality
Tammy De Leonardis
Administrative Assistant, Institute for Innovations in Care and Quality
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As part of HEN 1.0, 100 IL IHA HEN hospitals prevented
15,887 instances of patient harm for a cost savings of
$161.8 million between January 2012 and March 2014
 14,294 readmissions prevented;
 285 early-elective deliveries prevented;
 234 post-operative pulmonary embolisms
or incidents of deep vein thrombosis
prevented;
 192 central line-associated bloodstream
infections prevented;
 188 catheter-associated urinary tract
infections prevented;
 152 incidents of ventilator-associated
pneumonia prevented;
 131 surgical site infections prevented;
 126 birth trauma or injuries to neonates
prevented;
 123 pressure ulcers prevented;
 116 falls with injury prevented; and
 46 manifestations of poor glycemic control
prevented.
http://www.ihatoday.org/IHA-Institute/Raising-the-Bar.aspx
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IL IHA HEN 1.0 Results
AHA/HRET: Achievement of Targets – November 2014
AREA
At least 60%
Reporting
At least 70%
Reporting
ADE

CAUTI


CLABSI


Falls


OB-EED


OB-Other


PrU


SSI


Readm


VAP/VAE


VTE


At least 80%
Reporting

100% reporting

100% reporting

60%-53% reporting

90% reporting

98% reporting

100% reporting

100% reporting

100% reporting

100% reporting

100% reporting
17.6% Change
from Baseline
(15% Readm)
AND At Least
60% Reporting
40% Change from
Baseline (20% Readm)
AND At Least 80%
Reporting
Met High
Perf.
Benchmk
Achievement
of Target

33% reduction

61% reduction


9% reduction/
25% reduction

79% reduction

41% reduction

28% reduction




23% reduction

42% reduction

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CMS Partnership for Patients
Hospital Engagement Network 2.0
“The Hospital Engagement Network (HEN) will engage the hospital,
provider and broader caregiver communities to quickly implement welltested, evidence-based harm and measured best practices… the end
result of the overall initiative shall be reduction in hospital-based harm
and preventable readmissions.”
“Overall participation goal remains to recruit active participation of
100% of short-stay, acute care hospitals in the U.S.”
•
•
•
•
HEN 2.0 Request for Proposal announced on February 11, 2015
Request for Proposal response submitted on March 30, 2015
Anticipate funding and contract awards in third quarter (July) 2015
12-month contract
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IHA Institute’s Primary Goal
To Provide the Highest Degree of Sustainable Value for
Illinois Hospitals
Prime Contractor selection criteria:
1. Dedicated to the implementation of evidence-based best
practices
2. Utilizes proven methods to decrease hospital-acquired
conditions and improve patient safety culture
3. Access to hospital, state and national patient safety experts
4. Strongly supports minimum data collection and reporting
burden philosophy
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Announcing!
MHA-IHA HEN Partnership
• Should HEN 2.0 be funded and contracts awarded, IHA will be
subcontracting with the Michigan Hospital Association’s (MHA)
Keystone Center for the HEN 2.0 contract
• MHA’s Keystone Center successfully facilitated their own HEN
from 2012-2014 and was among the top HENs in the country
from a performance perspective (ACT score)
• While we had an amazing experience with AHA, we know that
subcontracting with MHA will put our IL hospitals in the most
optimal and sustainable position during the HEN 2.0 year and
moving forward beyond HEN
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HEN 2.0 Focus Areas
– Same as HEN 1.0 (40%/20% Reductions)
 Catheter-associated urinary tract infections (CAUTI), in all hospital settings,
including avoiding placement of catheters both in the ER and in the hospital
 Central line-associated blood stream infections (CLABSI), in all hospital
settings, not only in ICUs
 Ventilator-Associated Events (VAE), to include Infection-related VentilatorAssociated Complication (iVAC) and Ventilator-Associated Conditions (VAC)
 Surgical site infections, to include measurement and improvement of SSI for
multiple classes of surgeries
 Obstetrical adverse events, including early elective delivery, obstetrical
hemorrhage, and preeclampsia treatment and management to prevent
maternal morbidity and mortality
 Adverse drug events (ADE)
• Participating hospitals that have a primarily adult population must report
measures related to opioid safety, anticoagulation safety and glycemic
management, at a minimum
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HEN 2.0 Focus Areas
– Same as HEN 1.0 (40%/20% Reductions)
 Readmissions
 Injuries from falls and immobility
 Pressure ulcers
 Venous thromboembolism (VTE), including, at a minimum, all surgical settings
Additional topics for consideration
•
•
•
•
•
•
•
Severe Sepsis and Septic Shock
Hospital Culture of Safety (fully integrating patient safety with worker safety)
Iatrogenic Delirium
Clostridium Difficile (C.Dif.), including antibiotic stewardship
Undue Exposure to Radiation
Airway Safety
Failure to Rescue
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Minimum Participation
4 Requirements
1. Signed Commitment Letter (HEN Lead, CEO, CMO, CNO)
2. Submission of monthly data set
• 30 measures in all, includes 6 Hospital directly reported
• Baseline year: 2010
3. Signed Data Use Agreement
4. Engagement in foundational education focused on Culture,
High Reliability, and Patient and Family Engagement
initiatives (Specifics TBD-meaningful, value added education)
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MHA-IHA HEN Participation
Benefits
1. Access to high-quality resources, tools, webinars, and other
materials to support your improvement work on the HEN
2. Access to a data system to track progress on all applicable topics
including reports
3. Access to national subject matter experts who can assist with
improvement questions and recommendations
4. Opportunities to network, in-person and virtual, and access to
shared forums to assist improvement teams with barriers and
provide encouragement to continue the improvement journey
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MHA-IHA HEN Participation
(even more) Benefits
5. Opportunity to train staff in Quality Improvement principles through the QHR
“Quality Boot Camp” at no cost
6. Opportunity to train and certify staff in patient safety, healthcare quality, and
infection prevention (CPPS/CPHQ/CIC) at no cost
7. Opportunity to engage a physician from your organization in training and
certification through the American Board of Quality Assurance and Utilization
Review Physicians (ABQAURP)
8. Opportunity to compete for 1 of 20 slots in our “Go to the IHI on the IHA” friendly
competition
9. The Quality Department of your organization will receive a direct financial incentive
when you return the commitment letter and DUA to IHA with HEN Lead, CEO,
CMO, & CNO signatures within 60 days of receiving it
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MHA-IHA Approach to HEN 2.0
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Deeper Dive into the
MHA-IHA Collaboratives
Structure – Kick-off in-person meeting, followed by monthly webinars and
coaching calls with national experts. Each collaborative collects baseline
and monthly data to ensure progress is made and sustained.
Collaboratives utilize the Johns Hopkins University 4Es methodology:
Engage: Share stories and baseline data that show how the project will
improve culture and patient outcomes.
Educate: Educate staff on evidence and interventions needed for change to
occur.
Execute: Standardize procedures, create independent checks, learn from
mistakes and empower staff to pause a procedure if they see a potential
error, safety or quality issue.
Evaluate: View infections or harm as defects in care and provide feedback on
performance.
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Polling Question
If you were to join the MHA-IHA HEN, would you be interested in
participating in the CAUTI Keystone collaborative during HEN 2.0?
Interventions: assess current Foley catheter practices, implement
CAUTI reduction practices, and educate staff and patients
1.
2.
3.
4.
Yes
Maybe
Doubt it
No
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Polling Question
If you were to join the MHA-IHA HEN, would you be interested in
participating in the PAIN MANAGEMENT Keystone collaborative
during HEN 2.0?
Objectives: to address appropriate pain management in the
hospital setting and decrease the usage of opiates statewide
1.
2.
3.
4.
Yes
Maybe
Doubt it
No
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Polling Question
If you were to join the MHA-IHA HEN, would you be interested in
participating in the OBSTETRICS Keystone collaborative during HEN
2.0?
Focuses on reducing risk of/and maternal and neonatal morbidity
and mortality related to postpartum hemorrhage and
preeclampsia
1.
2.
3.
4.
Yes
Maybe
Doubt it
No
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Polling Question
If you were to join the MHA-IHA HEN, would you be interested in
participating in the National CUSP 4 MVP-VAP Keystone
collaborative during HEN 2.0?
Objective: to reduce ventilator- associated events in hospitals
using proven effective interventions
1.
2.
3.
4.
Yes
Maybe
Doubt it
No
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Polling Question
If you were to join the MHA-IHA HEN, would you be interested in
participating in the ICU SEPSIS Keystone collaborative during HEN
2.0?
Objectives: prevent harm through implementation of bundles of
interventions that ensure patients receive appropriate treatment
for their condition and reduce the likelihood that a patient will die
from severe sepsis or septic shock
1. Yes
2. Maybe
3. Doubt it
4. No
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Polling Question
If you were to join the MHA-IHA HEN, would you be interested in
participating in the ICU DELIRIUM AND EARLY MOBILITY Keystone
collaborative during HEN 2.0?
Interventions include: delirium assessment/management, and
identification and management of progressive mobility
1.
2.
3.
4.
Yes
Maybe
Doubt it
No
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HEN 2.0 Data Reporting
30 required measures
10 Measures reported
for you by IHA’s
CompData
ADE-1
OB-3
14 Measures reported
for you by conferring
rights to MHA-IHA
CAUTI3
CLABSI3
SSI-4
6 Hospital directlyreported measures
ADE-3
Falls-1
OB-EED
& PPH
Pressure ReadmitsUlcer-1
3
VAE-2
VTE-1
Sepsis-1
C.Dif-1
MRSA 1
6 Hospital Directly-Reported Measures:
OB-EED (JC PC-01), Post-Partum Hemorrhage (JC/ACOG/CMQCC)
ADE-Anticoagulant, Hypoglycemic, Opioid
Falls-Falls with injury (NQF 0202)
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Data Platform
• Bye bye CDS!
• MHA has contracted with
Battelle, a 501(c)(3) charitable
trust to develop our data
platform
• We are in the process of
working with Battelle to
develop reports and portal
functionality
• Hospitals will still enter
numerator/denominator data
and be able to run reports
Battelle is the world’s largest
nonprofit research and
development organization.
Battelle was founded on
industrialist Gordon Battelle’s
vision that business and
scientific interests can go
hand-in-hand as forces for
positive change.
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HEN 2.0 Commitment Letter
Eligibility and Recruitment: CMS is strongly urging 100 percent
of short-stay, acute care U.S. hospitals to participate. As with
HEN 1.0, hospitals are eligible to join any HEN but they may only
join one HEN. A letter of engagement committing the
organization to one HEN must be signed by the participating
organization’s CEO and other C-suite executive sponsors within
60 days of project start.
• A commitment letter will be sent out once CMS funds the
project and the primary contracts are awarded requiring
signatures from the HEN Lead, CEO, CMO and CNO.
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MHA-IHA HEN
• Our aim in HEN 2.0 is to provide you with an enhanced level
of resources, networking and coaching to assist you in
advancing your Quality Improvement and Patient Safety
agendas
• IHA and MHA staff are hard at work planning an array of
content webinars and educational opportunities that will
cover all 11 focus areas in HEN 2.0
• We are committed to providing you with a highly valued and
successful initiative that will help IL hospitals meet and exceed
national goals for the HEN year and beyond
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Partnering Across the Continuum…
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Next Steps…
• Signed Commitment Letter & Data Use Agreement
• You will receive the documents after the project is funded
and the contracts are awarded (Quarter 3, 2015)
• Commitment letter & Data Use Agreement signatures must
be obtained within 60 days to receive the financial incentive
• Look for the monthly Institute Insights newsletter to keep you
informed. Contact TDeLeonardis@ihastaff.org to add yourself
• HEN 2.0 Metrics
• Full list of 30 metrics available upon request
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One Final Polling Question
Are you interested in joining the
MHA-IHA HEN in 2015-2016?
1.
2.
3.
4.
Yes
Maybe
Doubt it
No
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Thank you 
Questions?
Adam Kohlrus
Director, Performance
Improvement
IHA,
akohlrus@ihastaff.org
217-541-1181
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