HEN Performance Improvement: Delivering More than Numbers

Transcription

1 HEN Performance Improvement: Delivering More than Numbers 100 E. Grand Ave., Ste. 360 Des Moines, IA Office: Fax: History of Iowa s HEN A year into Partnership for Patients and the Hospital Engagement Network what have we learned? Partnership for Patients developed by CMS/CMMI (Innovation Center) 100% of Iowa hospitals sign on to be included CMMI selected 10 focus areas where healthcare costs and quality could/would be impacted most if the events happened less often 1

2 History of Iowa s HEN A year into Partnership for Patients and the Hospital Engagement Network what have we learned? Iowa Healthcare Collaborative awarded HEN contract HEN participating hospital CEOs (Iowa and bordering state facilities) sign pledge to participate Website designed to collect monthly data points on process and outcome metrics for ten focus areas History of Iowa s HEN A year into Partnership for Patients and the Hospital Engagement Network what have we learned? Faced with a challenge on how to collect data, IHC elected to optimize what is already being done in participating hospitals IHC developed suggested preset metrics for at least one process and one outcome per focus BUT also allowed hospitals to select metrics that align with other external/internal data collections to avoid adding to already overburdened quality/infection prevention staff. 2

3 PfP Website Data Collection Tool/Reports IHC Partnership for Patients (PfP) Reporting Tool developed Participating facilities completed a work plan to communicate plans for improvement Hospitals can opt out of focus areas that their facility does not perform Data entry Using available reports Data entry of selected metrics done by hospital staff Progress of each reported metric is immediately available after month data entry is complete Information at this level is for your eyes only 3

4 Data entry Using available reports Data due 45 days after the end of a month Reminder messages sent to all will communicate deadline 60 days after the end of a month, non-reporting hospital CEOs and quality/infection prevention contacts will be notified if no data submitted Data entry Using available reports Problems with run charts should be reported to IHC/IAs as soon as they are noticed Issue may include: Custom metrics lack labels Like metric data on graphs are not showing up on the same run chart Data missing 4

5 PfP Website Data Collection Tool/Reports Anyone experiencing difficulty with the program CONTACT YOUR IMPROVEMENT ADVISOR OR CALL IHC This includes: Registering new users Logging in Completing a work plan Selecting metrics that make sense Entering/completing monthly data Correcting edits Running reports Understanding what reports mean UPDATE WORK PLANS! GET YOUR DATA IN NOW! USE THE RUN CHARTS! Next steps.what you can do. It is strongly suggested that you incorporate HEN run charts into local staff meetings, quality committees, boards, etc. If you haven t started no time like the present! Begin reporting metrics that have no data yet (maybe reporting 0 denominator) 5

6 Next steps.what you can do. Add users if that would help as many as you need Provide feedback to make data collection tool to make information meaningful and useful Re-evaluate/simplify data collection and reporting make it work for you! Challenge yourselves to work on opportunities where you know work is needed Change metrics if the time is right (PDSA) It is time to transition from how to enter data to how are results used for improvement! Thank you! WHAT YOU DO DOES MAKE A DIFFERENCE!! 6

7 PfP Scope of Work Readmissions Adverse drug events Venous Thromboembolism (VTE) Falls Pressure Ulcers OB adverse events Catheter associated UTI Surgical Site Infection (SSI) Ventilator-associated Pneumonia (VAP) Central line infection HEN Measure Set- Readmissions Readmissions Outcomes: June 2012 January 2013: 16.8% improvement 7

8 HEN Measure Set- Early Elective Deliveries (EED) HEN Measure Set- Early Elective Deliveries (EED) OB EED Rate from May 2012 January 2013: 64.5% Improvement 8

9 HEN Measure Set- Adverse Drug Events (ADE) INRs May Jan: 30.66% improvement HEN Measure Set- Adverse Drug Events (ADE) Per 1,000 Patient Days: May 2012 January 2013: 71.5% improvement 9

10 HEN Measure Set- Falls & Immobility June 2012 January 2013: Falls with moderate injury: 61.49% improvement HEN Measure Set- Pressure Ulcers June 2012 January 2013: High performing below.01 per 1000 patient days 10

11 HEN Measure Set- Catheter Associated Urinary Tract Infections (CAUTI) CAUTI Outcomes: June 2012 January 2013: 38.24% improvement HEN Measure Set- Central Line Associated Blood Stream Infections (CLABSI) CLABSI Outcome: June January 2013: 51.26% 11

12 HEN Measure Set- Ventilator-Associated Pneumonia (VAP) VAP Outcomes: June 2012 January 2013: 72.26% improvement HEN Measure Set- Surgical Site Infections (SSI) SSI Outcome: June 2012 January 2013: 56.87% improvement 12

13 HEN Measure Set- Venous Thromboembolism (VTE) VTE Outcome: July 2012 January 2013: 49% improvement Improvement Z Scale Improvement Capability 1- Participating in learning communities 2- Monthly reporting performance data 3- Demonstrate improvement 4- Sustainable improvement 5- Mentor others 13

14 April Formative Evaluation Report HSAG/Mathematica; April 2013 April Formative Evaluation Report HSAG/Mathematica; April

15 April Formative Evaluation Report HSAG/Mathematica; April 2013 April Formative Evaluation Report HSAG/Mathematica; April

16 April Formative Evaluation Report HSAG/Mathematica; April

17 April Formative Evaluation Report HSAG/Mathematica; April 2013 Evidence of Improvement and Estimation of Value 100 E. Grand Ave., Ste. 360 Des Moines, IA Office: Fax:

18 Evidence of Improvement Over Time? Analytical Approach Jan June 2012 Baseline Pre QI July Dec 2012 QI Period Jan March 2013 Post QI TIME >>>>>>> For Each HEN Focus Area Calculation of number of events Avoided or Incurred o Expected Events Actual Events o HEN-wide Analytical Approach Estimation of Value Sources o Literature o CMS estimates o IHC applied research 3 major categories evaluated o Cost (Cost-to-Charge, 2012 CPI-U adjusted) o LOS o Mortality 18

19 ADE PfP Area Events Cost LOS Mortality Blood Glucose 313 Min $ 958, Max $ 2,642, INR 40 Min $ 122, Max $ 337, ADE Totals 353 Min $ 1,080, Max $ 2,979, OB - EED PfP Area Events Cost LOS Mortality EED 10 $ 438,

20 VTE PfP Area Events Cost LOS Mortality VTE -1 Min - $ 7, Max - $ 14, Falls PfP Area Events Cost LOS Mortality Falls - All 6 Min $ 35,026 N/A N/A Max $ 39,138 N/A N/A 20

21 Pressure Ulcers PfP Area Events Cost LOS Mortality PUs -7 Min - $ 16, Max - $ 50, CLABSI PfP Area Events Cost LOS Mortality CLABSIs 0 Min $ Max $

22 CAUTI PfP Area Events Cost LOS Mortality CAUTI 9 Min $ 7,523 N/A N/A Max $ 28,913 N/A N/A VAP PfP Area Events Cost LOS Mortality VAP 2 Min $ 23, N/A Max $ 129, N/A 22

23 SSI PfP Area Events Cost LOS Mortality SSI 43 Min $ 527,900 N/A N/A Max $ 1,401,912 N/A N/A Readmission PfP Area Events Cost LOS Mortality Readm 660 Min $ 6,721,440 3,102 N/A Max $ 6,791,334 3,102 N/A 23

24 Thank You 100 E. Grand Ave., Ste. 360 Des Moines, IA Office: Fax: