2 nd Annual PPS Quality and Patient Safety Conference
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1 2 nd Annual PPS Quality and Patient Safety Conference Jointly Sponsored by MHA and Stratis Health Welcome and Introduction Jennifer Lundblad, PhD, MBA, President & CEO, Stratis Health
2 Healthcare-Centric vs. Person-Centric Clinic Mall Hospital Nursing Home Hospital Clinic TCU Church Park School Home Home Care Hospice 1
3 Welcome to Lake Wobegon, where all the women are strong, all the men are good-looking, and all the children are above average. Garrison Keillor 2
4 So are we? 3
5 CMS Value-Based Purchasing (VBP) 4
6 CMS VBP 5
7 Coordination of Care 6
8 Coordination of Care Communities 7
9 Coordination of Care Communities 8 communities 681 participants 23 workgroups 272 organizations 15 assisted living facilities 20 clinics 52 home health agencies 6 hospice programs 47 hospitals (29 PPS; 18 CAH) 102 nursing homes 21 pharmacists 19 community organizations/ government groups 8
10 Community Readmission Rate Comparison 9
11 Focus Areas Medication-related issues 10 Advance care planning 4 Communication 4 Discharge processes 2 Care pathways 2 Care transition education Exacerbation of chronic conditions (CHF/COPD) Health literacy Lack of resources/pt engagement NH capabilities Social support 10
12 CMS Readmission Reduction FY2016 Readmission Reduction Minnesota Performance Hospital Adjustment Factor Table 15 CMS.gov Hospitals receiving a penalty (up to 3% in FY2016) 11
13 Healthcare-Associated Infection (HAI) 12
14 13
15 CMS HAC FY2016 Hospital Acquired Condition Scores Minnesota December 2015 CMS.gov Top 25% receive 1% penalty 14
16 Nursing Home Initiatives 15
17 Building Improvement Capacity 16
18 Clinic Initiatives 17
19 Clinic Priorities Diabetes Focus: Diabetes Empowerment Education (DEEP) Diabetes Self-Management (DSMP) Cardiac Focus: Hypertension Smoking Cessation Behavioral Health Focus: Depression screening Substance use screening Readmissions 18
20 Quality Reporting and Value-Based Purchasing: National and Minnesota National Culture Strategies AHRQ Patient Safety Survey (HSOPS) Comprehensive Unit-based Safety (CUSP) Transforming Care at the Bedside (TCAB) Specific to Minnesota SAFE Roadmap CMS Incentive s Hospital Valuebased Purchasing (VBP) Hospital Acquired Condition (HAC) Hospital Readmission Reduction (HRRP) Hospital Meaningful Use erx Incentive Physician Value- Modifier/Feedback Physician Office Meaningful Use Merit-Based Incentive Payment System (MIPS) CMS Quality Reporting s Hospital Inpatient Quality Reporting (IQR) Hospital Outpatient Quality Reporting (OQR) Ambulator y Surgery Center Quality Reporting (ASCQR) Physician Quality Reporting System (PQRS) Acute Care Episodic/Transition to Acute Care Inpatient Psychiatric Facilities Quality Reporting (IPFQR) Ambulatory Care Home Health Quality Reporting (HH QRP) Statewide Quality Reporting and Measurement System (SQRMS) Inpatient Rehab Facility Quality Reporting (IRF QRP) Hospice Quality Reporting Specific to Minnesota Long Term Care Hospital Quality Reporting (LTCHQR) PPS Exempt Cancer Hospital Quality Reporting (PCHQR) Nursing Home Compare (MDS data) Adverse Health Events Reporting
21 Evolution of Hospital Pay for Reporting and Pay for Performance s Inpatient Quality Reporting (Supported by QIO) Value-based Purchasing (Supported by QIN-QIO) Readmission Reduction (Supported by RARE) Hospital Acquired Condition (Supported by CHAIN) Meaningful use (Supported by REACH) Accountable Care Organizations(ACO) erx Incentive (Supported by QIO) Practice Transformation Networks (PTN) Physician Quality Reporting System (Supported by QIO) Meaningful Use (Supported by REACH) Physician Value- Modifier (Supported by QIN-QIO) Merit-based Incentive Payment (MIPS)
22 Agenda for Today 21
23 Objectives Identify strategies that will positively impact your organization s interdisciplinary teamwork and resiliency Explore ways to organize quality responsibilities within your hospital/system Describe best practices for improving performance on value-based purchasing (VBP) and surgical site infection (SSI) Understand how you can use daily safety huddles to identify and resolve issues efficiently and increase overall leadership situational awareness 22
24 Inspire People Improve on VBP Our Learnings Today Stratis Health Networking Improve on SSI Daily Safety Huddles Inspire People MHA 23
25 Morning Agenda 9:00 a.m. Welcome and Introduction Jennifer Lundblad, PhD, MBA, President & CEO, Stratis Health 9:20 a.m. Interdisciplinary Teamwork and Relationships Teddie Potter, PhD, RN, FAAN, Clinical Associate Professor, University of Minnesota School of Nursing 10:20 a.m. Break 10:35 a.m. Learning from Value-Based Purchasing High Performers Glen Kegley, Chief Operating Officer, Hutchinson Health Andrea Hager, MS, CPHQ, Manager, Quality & Medical Staff Services, Mercy Hospital 24
26 Afternoon Agenda 12:35 p.m. Networking: Different ways to organize quality and patient safety responsibilities and implement strategies starting with a 15-minute presentation on the Fairview Readmission Summit, Beverly Christie, DNP, RN, Sr. Director for Integrated Quality & Patient Safety 1:35 p.m. Break 1:50 p.m. Slashing SSI Raising the Bar to Lower the Rate Lindsey Lesher, MPH, Consultant Epidemiologist (Session moderator) Kathleen Steinmann, MT (ASCP), CIC, Infection Preventionist, Hennepin County Medical Center Patricia Dumonceaux, MSN, RN PHN, CIC, Infection Prevention and Control, CentraCare Health St. Cloud Hospital Sharon Kim, Mayo Medical Student, Mayo Clinic 2:45 p.m. Daily Safety Huddles Abe Jacob, MD, MHA, Chief Medical Officer, University of Minnesota Masonic Children s Hospital 3:15 p.m. Resiliency- Journey of Hospital and Community Partnership Corey Martin, MD, Director of Medical Affairs, Buffalo Hospital 4:00 p.m. Closing Remarks Rahul Koranne, MD, Chief Medical Officer, Minnesota Hospital Association 25
27 This material was prepared by Lake Superior Quality Innovation Network, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The materials do not necessarily reflect CMS policy. 11SOW-MN-D
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