Welcome and Instructions

Transcription

1 Welcome and Instructions For audio, join by telephone at , participant code # Your line is OPEN. Please do not use the hold feature on your phone but do mute your line by dialing *6. If you are having technical difficulties, Please ask questions through the chat box or wait to the end of each section to ask the presenter 1

2 Welcome to the Kentucky Hospital Improvement Innovation Network - January Update

3 Agenda 1. Needs Assessments due ASAP no later than 1/30/17 2. Site Visits Update potential weather issues 3. Fellowships QI and PFE for Equity Pledge 5. SNAP Safety Network to Accelerate Performance 6. Data and Ky. Quality Counts Update 7. Topic-Based Info-Nuggets, Hospital Highlight, and Upcoming HRET Events 8. Timeline and Next Steps 3

4 Needs Assessment HRET Deadline 1/31/17 As of 1/25-83% completed thank you! Can be found on on Data page under Tools Complete and scan to or fax to (502)

5 Site Visits The K-HIIN team is on the road again! So far - 20 Visits completed, thank you! If it looks like inclement weather may impact travel, we will contact you directly to discuss. Sign up on Signup Genius - All times are in Eastern Time Zone just to make it less confusing If you don t see a good date/time for your hospital, contact us directly - dmeador@kyha.com or sperkins@kyha.com Preparation Complete Needs Assessment Invite key team members Senior Leadership, clinical leaders, data collectors and analysts, physician leaders, risk managers, IP, etc. Let us know location of meeting, media and Internet capabilities 5

6 Fellowships Back by popular demand! 1. QI Fellowships KY enrollment: Foundations for Change 13 enrollees Accelerating Improvement 4 enrollees 2. Patient and Family Engagement 6 enrollees Thank you for participating - there s still time to sign up for both remember, our goal is to have at least one Fellow from each hospital! 6

7 #123forEquity Disparities impact statement 7

8 #123ForEquity National Call to Action #123forEquity Pledge Pledge to address the following areas in the next 12 months- By end of month one, choose a quality measure to stratify by race, ethnicity, or language preference (or other socio-demographic variable such as income, veteran status, sexual orientation or gender, or other) By end of month three, determine if a health care disparity exists in this measure if yes, design a plan to address the gap By end of month six, provide cultural competency training for all staff or develop a plan to ensure your staff receives cult. comp. training By end of month nine, have a dialogue with board and leadership team on how you reflect the community you serve, and what actions can be taken to address any gaps if the board and leadership do not reflect the community you serve

9 Disparities impact statement To promote the #123forEquity pledge, the IFD and the Disparities Solutions Center (DSC) at Massachusetts General Hospital are partnering to provide practical, actionable strategies to help HIIN hospitals meet the goals of the pledge by conducting regional Improving Quality and Achieving Equity trainings hosted by HIIN state hospital associations on a quarterly basis. The curriculum focuses on how to execute on each component of the pledge; leaders will then take these concrete strategies back to their hospitals to facilitate their successful execution, thus contributing to improving quality and diversity, eliminating disparities and achieving equity. Subject matter experts will help the participants develop a blueprint for action that they can share and present to their organizations as a guide along with the #123ForEquity Toolkit. More information to come!

10 Oh SNAP! What is SNAP? Safety Network to Accelerate Performance The first SNAP topic is enhanced recovery after surgery with a focus on colorectal surgery. The SNAP page and application are now on the HRET HIIN website. Hospitals that are interested in participating in this SNAP should register for the informational call on February 2 at 2:00 p.m. CT. The registration link is available on the 'SNAP' and 'Upcoming Events' pages of the website. 10

11 DATA UPDATE 11

12 Baseline Periods Preferred Baseline Periods Calendar year 2014 except: SIRs Calendar year 2015 to be collected after the NHSN rebaseline is completed in Dec 2016 CAUTI & CLABSI Calendar year 2015 Alternate Baseline Periods Oldest 12, 9, 6, or 3 month consecutive period prior to Oct 2016 All Baseline Data Due to KHIIN January 27,

13 Baseline Periods 13

14 Data Submission MONTHLY Beginning Oct 2016 Site collected data will be entered into the KQC system by the hospital Site collected measures specific to your hospital will show up on your KQC data entry page 14

15 KY Quality Counts Data Collection System 15

16 New Measures to HIIN Readmissions Readmission Hospital Wide Medicare Only Culture of Safety Worker Safety Harm events related to patient handling Harm events related to workplace violence 16

17 Readmissions Hospital Wide/Medicare Measure is a subset of the All Payor measure Specifications are the same except it applies only to Medicare patients Collect your data for All Payors first, then filter on only Medicare patients 17

18 Culture of Safety - Worker Safety Harm events related to patient handling Numerator Number of worker harm events related to patient handling for the time period Denominator Number of full-time equivalents (FTEs) for the time period Harm events related to workplace violence Numerator Number of worker harm events related to workplace violence for the time period Denominator Number of full-time equivalents (FTEs) for the time period 18

19 Worker Safety Data Sources Numerators obtain from the OSHA 300 log Recordable injuries include Death Loss of consciousness Days away from work Restricted work activity or job transfer or Medical treatment beyond first aid Denominator obtain from Human Resources 19

20 OSHA 300 Log 20

21 Data Sources Core Topic Site NHSN AHRQ ADE CAUTI CLABSI C. diff Falls Pressure Ulcer (Prevalence) (Rate) Readmissions Sepsis SSI VTE VAE 21

22 Data Sources Additional Topics Site NHSN AHRQ MRSA Culture of Safety Worker Safety* *Worker Safety measures are already collected on the OSHA Log 22

23 And a Few Info-Nuggets Adverse Drug Events 23

24 Antibiotic Stewardship Program Checklist for Core Elements of Hospital Antibiotic Stewardship Program: Leadership Support Accountability Drug Expertise Actions to Support Optimal Antibiotic Use Tracking: Monitoring Antibiotic Prescribing, Use and Resistance Reporting Information to Staff on Improving Antibiotic Use and Resistance Education 24

25 Pharmacy Champions Looking for Pharmacy Champions!!! Complete your Pharmacy Survey today It is not too LATE.54 have been received as of Monday, January 23 I m missing yours!!! 25

26 And a Few Info-Nuggets Readmission Views From the Road Readmissions are expensive Readmission are a significant part of Quality Improvement Many tools are being used including LACE, RED, Special Projects, Data Analysis Hospitals are routinely involved in their communities to reduce readmission - outside the walls. Significant challenges exist with chronic conditions or CHF, COPD, Diabetes, Aging 26

27 Hospital Highlight Taylor Regional Engaging your Environmental Services Department in Infection Prevention Shannon Davis, RN IP at Taylor Regional Environmental Services Certification Course in Collaboration with Campbellsville University 27

28 Upcoming HRET Events HRET HIIN CLABSI Virtual Event January 26 from 12:00 p.m. 12:50 p.m. ET HRET HIIN QI Fellowship Foundations for Change Virtual Event #2 February 1 from 12:00 1:00 p.m. ET HRET HIIN QI Fellowship Accelerating Improvement Virtual Event #2 February 1 from 1:30 2:30 p.m. ET HRET HIIN VTE Virtual Event February

29 Upcoming HRET Events I Screen, You Screen, Let s All Screen for Sepsis! February 9 Adjuncts and Alternatives to Opioids for Pain: It s All About Love February

30 Timeline and Next Steps Needs Assessments complete and send if not done already Site Visits - Schedule yours now if not already scheduled Join the Fellowship! Continue entering Monitoring Data into KQC > KEEP CALM AND HIIN ON 30

31 Questions? 31