2017 Nicolas E. Davies Enterprise Award of Excellence
|
|
- Gerald Thomas
- 5 years ago
- Views:
Transcription
1 2017 Nicolas E. Davies Enterprise Award of Excellence
2 Agenda Memorial Hermann Health System Overview Journey to High Reliability Case study review CLABSI Prevention 2
3 Memorial Hermann Health System Woodlands Sugar Land TMC Katy Memorial City Southeast Total hospitals: 15 (11 acute, 2 rehab, 1 children s, 1 orthopedic) Inpatient admissions: 158,241 Annual emergency visits: 595,611 Annual deliveries: 25,146 Employees: 25,040 Beds (acute licensed): 4,016 Medical staff members: 5,708 Fellowship programs: 48 Greater Heights Northeast Cypress Pearland Children s Southwest TIRR Katy Rehab MHOSH
4 Our Network of Care 292 Care Delivery Sites 4
5 15 Certified Zero Awards 32
6 Memorial Hermann Recent Accolades Quality A competitive advantage for Memorial Hermann 15 Top Health Systems; Top 5 Large Health Systems (2012 & 2013) John M. Eisenberg National Patient Safety & Quality Award (2012) National Quality Forum National Quality Healthcare Award (2009) TIRR Memorial Hermann No. 2 in rehabilitation hospitals Texas Hospital Association Bill Aston Quality Award (2011) America s #1 Quality Hospital for Overall Care (2011 & 2012) Healthcare s 100 Most Wired 12 th consecutive year America s 50 Best Hospitals ( ) The Joint Commission Top Performer (2012), Heart Attack, Heart Failure, Pneumonia, Surgical Care 2011 Texas Healthcare Foundation Quality Improvement Awards (9 Memorial Hermann Campuses) 2015 Houston Business Journal (HBJ) No. 3 Best Places to Work
7 Memorial Hermann ACO ~4,000 MHMD Physicians, ~3,500 CIN Clinically Integrated Network Private, Employed & Faculty Integration 3 DISTINCT PRACTICE MODELS Employment Faculty Private Population Health Infrastructure 7
8 Memorial Hermann ACO High Moderate Degree of Risk Shifting to Providers TIER III Value Driven 501,447 Members TIER II Gain Sharing Community Health Choice 54,740 TIER I Partial -Full Risk CMS MSSP 47,400 Aetna Commercial 85,000 Humana Commercial 18,700 Aetna Medicare Advantage 5,800 Humana Medicare Advantage 5,000 United Healthcare Medicare Advantage 8,800 BCBS Commercial 75,000 United Healthcare Commercial 100,000 MH Health Plan Commercial MHHS 39,136 Other 28,881 MH Health Plan Medicare Advantage 6,790 Aetna Whole Health 26, ,700 Lives 101,007 Lives Low Fragmented Transitioning Integrated Increasing Degree of Integration Delivery System Readiness for Risk 8
9 Our Journey High Reliability Organization 9 Commercial Aviation Nuclear Aircraft Carriers Air Traffic Control
10 High Reliability Certified Zero Award 1. Zero Events Consecutive Months 3. Certified Zero Category
11
12 High Reliability Certified Zero Awards 12 ICU Central Line Associated Bloodstream Infections (18) ICU Catheter Associated Urinary Tract Infections (16) Hospital-Wide Central Line Associated Bloodstream Infections (7) Hospital-Wide Catheter Associated Urinary Tract Infections (5) Ventilator Associated Pneumonias (23) Retained Foreign Bodies (46) 263 Iatrogenic Pneumothorax (24) Accidental Punctures and Lacerations (3) Pressure Ulcers Stages III & IV (37) Hospital Associated Injuries (7) Deep Vein Thrombosis and/or Pulmonary Embolism (2) Deaths Among Surgical Inpatients with Serious Treatable Complications (1) Birth Traumas (16) Obstetric Trauma in Natural Deliveries with Instrumentation (4) Serious Safety Events 1&2 (21) Serious Safety Events 1 & 2 for 1000 Days (2) All Serious Safety Events (1) Early Elective Deliveries (9) Manifestations of Poor Glycemic Control (21)
13 Wall of Pride! Memorial Hermann Facility
14 CLABSI Prevention: An Infectious Story - Siraj Anwar
15 Background Challenges Governance & Design Implementation & Monitoring Financial Impact Lessons Learned 15
16 Background Central Line Associated Blood Stream Infections 1,2,3,4 Common Costly (~$45,000) Lethal (~28,000 Deaths) 1. Association for Professionals in Infection Control and Epidemiology/ CDC 2. Mermel LA. Prevention of intravascular catheter-related infections. Ann Intern Med 2000;132: [Erratum, Ann Intern Med 2000;133:5.] 3. Burke JP. Infection control a problem for patient safety. N Engl J Med 2003; 348: O Grady NP, Alexander M, Dellinger EP, et al. Guidelines for the prevention of intravascular catheter-related infections.
17 Challenges Complexity of Memorial Hermann 15 Hospitals 66 ICUs 965 ICU Beds ~ 8400 Central Line Days/Month
18 Adult ICU Central Line Associated Blood Stream Infections (CLABSI) 18
19 Is It Possible? 108 ICU s, 1981 ICU-months, 375,757 catheter days [T]he median rate per 1000 catheter days decreased to 0 at 3 months.
20 Design Implementation Governance
21 Burning Platform
22 Governance Stakeholder Meeting Clinical & Operational Leaders Physicians Nursing Infection Control Quality
23 Design and Implementation Joint Application Design (JAD) Sessions Clinical Stakeholders Application Analysts/ Experts Clinical Informaticists Key Design Decisions Functionality Data Elements Reporting
24 Operational Changes High Visibility Board & Senior Leaders Patient Safety Priority for everyone Empowering Staff to Say No Appropriate Supplies Available
25 Operational Changes Use of documentation bundles Infection Attribution Physician Nursing Unit Periodic Review of Data Daily Exception Report Monthly Report (Nursing Unit, Facility, System)
26 Central Line Insertion Bundle Elements MD Hand Hygiene Chlorahexadine Use MD gown, gloves, hat & mask Drape patient from head to toe Sterile field maintained during procedure Assistant gown, gloves, hat & mask
27 Central Line Maintenance Bundle Elements CVC dressing occlusive & intact Site healthy w/o redness or drainage Dressing change: < 7 days for transparent < 2 days for gauze CL Dressing Change Compliance CL Dressing Labeled with date/time All CVC tubing labeled with date/time All CVC tubing labeled with date/time of insertion
28 CLABSI Prevention Timeline of Events May 2007 Bundle Implementation on Paper Conversion to EHR Mar 2010 Electronic Abstraction 2013 Change to CLIP Electronic Documentation Continuous surveillance of: 1. Clinical Outcomes 2. CLABSI Bundle Compliance 2016 Change to CL Maintenance Documentation 2016 Physician Line Necessity Documentation 28
29 How Health IT was Utilized
30 Workflow With Health IT Interventions
31 Central Line Insertion Documentation Bundle Patient drape, head to toe? Sterile gown, gloves and mask? Skin prep dry before insertion? Ultrasound used? 31
32 Process Measures Central Line Insertion
33 Central Line Maintenance Documentation Bundle Dressing occlusive and Intact? Dressing Changed? Labeled with Insertion Date?
34 Process Measures Central Line Maintenance
35 Central Line Necessity Documentation Form
36 Process Measures Central Line Necessity
37 Central Line Necessity Next Steps Automation of necessity documentation Identify patients with central line Alert physician Patient chart open Add/ sign order Passive notification 37
38 Central Line Insertion Bundle Compliance 38
39 Central Line Maintenance Bundle Compliance 39
40 Our Journey.. CLABSI Rate 40
41 High Reliability! Certified Zero Awards 25 Certified Zero Awards for CLABSI Prevention 41
42 High Reliability! Certified Zero Awards 42 Zero CLABSIs Hospital-Wide x 17 Months
43 Financial Impact ICUs Only Central Line Days/ Month ( ) ~8472 Current Infection Rate ( ) 0.92 Previous Infection Rate (2007) ~5.79 Projected Difference in Infections (49)-(8)= 41 Infections Prevented/Month 41 x ~45,000 = ~$1.84 Million/Month Infections Avoided in CY : 984 Cost Avoidance for CY : ~44 Million
44 Lessons Learned Stakeholder buy-in Improvement driven through data Accountability is key Change to data elements? HOLD YOUR HORSES!!
45 Closing Thoughts. People Relationships Process (People) Technology (People)
46 THANK YOU! 46
Building a Culture That Lasts
Building a Culture That Lasts Establishing a Leadership Legacy Quality Texas Foundation June 28, 2016 M. Michael Shabot, MD, FACS, FCCM, FACMI Executive Vice President System Chief Clinical Officer V2
More informationRole of the C-Suite in High Reliability Antimicrobial Stewardship
Role of the C-Suite in High Reliability Antimicrobial Stewardship 1 st Annual Texas Medical Center Antimicrobial Resistance and Stewardship Conference January 19, 2018 M. Michael Shabot, MD, FACS, FCCM,
More informationEstablishing a Culture of Quality and Safety and the Journey to High Reliability
Establishing a Culture of Quality and Safety and the Journey to High Reliability Becker s Hospital Review May 9, 2013 Charles D. Stokes System Chief Operating Officer M. Michael Shabot, M.D. System Chief
More informationCommitment to Zero Harm:
1 Commitment to Zero Harm: Memorial Hermann Health System s Journey to High Reliability MHA Patient Safety & Quality Symposium March 8, 2017 M. Michael Shabot, MD, FACS, FCCM, FACMI Executive Vice President
More informationDelivering Standardized Evidencebased Practice to Improve Quality and Contain Costs
Delivering Standardized Evidencebased Practice to Improve Quality and Contain Costs Robert E Murphy, MD Chief Medical Informatics Officer Memorial Hermann Healthcare System HIMSS Webinar November 21, 2013
More informationImplementation Guide for Central Line Associated Blood Stream Infection
Implementation Guide for Central Line Associated Blood Stream Infection March 27, 2013 Contents 1. Introduction... 3 2. Central Line Associated Blood Stream Infection Prevention Evidence-Based Practices...
More informationHigh Reliability & Robust Process Improvement
High Reliability & Robust Process Improvement M. Michael Shabot, MD, FACS, FCCM, FACMI EVP & Chief Clinical Officer, Memorial Hermann Health System Session A16 & B16 The presenters have nothing to disclose
More informationScoring Methodology FALL 2016
Scoring Methodology FALL 2016 CONTENTS What is the Hospital Safety Grade?... 4 Eligible Hospitals... 4 Measures... 5 Measure Descriptions... 7 Process/Structural Measures... 7 Computerized Physician Order
More informationScoring Methodology FALL 2017
Scoring Methodology FALL 2017 CONTENTS What is the Hospital Safety Grade?... 4 Eligible Hospitals... 4 Measures... 5 Measure Descriptions... 9 Process/Structural Measures... 9 Computerized Physician Order
More informationHigh Reliability and Robust Process Improvement
Session Code B15 The presenters have nothing to disclose High Reliability and Robust Process Improvement M. Michael Shabot, MD, FACS, FCCM, FACMI Memorial Hermann Health System Mark Chassin, MD, FACP,
More information(202) or CMS Proposals to Improve Quality of Care during Hospital Inpatient Stays
DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Room 352-G 200 Independence Avenue, SW Washington, DC 20201 FACT SHEET FOR IMMEDIATE RELEASE April 30, 2014 Contact: CMS Media
More informationSCORING METHODOLOGY APRIL 2014
SCORING METHODOLOGY APRIL 2014 HOSPITAL SAFETY SCORE Contents What is the Hospital Safety Score?... 4 Who is The Leapfrog Group?... 4 Eligible and Excluded Hospitals... 4 Scoring Methodology... 5 Measures...
More informationHOSPITAL ACQUIRED COMPLICATIONS. Shruti Scott, DO, MPH Department of Medicine UCI Hospitalist Program
HOSPITAL ACQUIRED COMPLICATIONS Shruti Scott, DO, MPH Department of Medicine UCI Hospitalist Program HOSPITAL ACQUIRED COMPLICATIONS (HACS) A medical condition or complication that a patient develops during
More informationCentral Vascular Catheter Insertion Checklist Standard Operating Procedure. Perform optimal care
Central Vascular Catheter Insertion Checklist Standard Operating Procedure Perform optimal care Improving process to improve outcome This checklist is adapted with kind permission from the checklist devised
More information1. Recommended Nurse Sensitive Outcome: Adult inpatients who reported how often their pain was controlled.
Testimony of Judith Shindul-Rothschild, Ph.D., RNPC Associate Professor William F. Connell School of Nursing, Boston College ICU Nurse Staffing Regulations October 29, 2014 Good morning members of the
More informationScoring Methodology SPRING 2018
Scoring Methodology SPRING 2018 CONTENTS What is the Hospital Safety Grade?... 4 Eligible Hospitals... 4 Measures... 6 Measure Descriptions... 9 Process/Structural Measures... 9 Computerized Physician
More informationDescribe the impact of CLABSI on patients and their families. Discuss three methods of reducing CLABSIs
Describe the impact of CLABSI on patients and their families. Discuss three methods of reducing CLABSIs Explore the essential elements of maintaining decreased CLABSIs 1 2001-43,000 CLABSIs In ICUs 2009-18,000
More informationCentral Line Bundle Education. National Patient Safety Goal Preventing Central Line Infections 2010
Central Line Bundle Education National Patient Safety Goal 07.04.01 Preventing Central Line Infections 2010 Central Line Associated Bloodstream Infections CAN and DO kill our patients. THE GOOD NEWS They
More informationCMS Quality Program- Outcome Measures. Kathy Wonderly RN, MSEd, CPHQ Consultant Developed: December 2015 Revised: January 2018
CMS Quality Program- Outcome Measures Kathy Wonderly RN, MSEd, CPHQ Consultant Developed: December 2015 Revised: January 2018 Philosophy The Centers for Medicare and Medicaid Services (CMS) is changing
More informationHospital Inpatient Quality Reporting (IQR) Program Measures (Calendar Year 2012 Discharges - Revised)
The purpose of this document is to provide a reference guide on submission and Hospital details for Quality Improvement Organizations (QIOs) and hospitals for the Hospital Inpatient Quality Reporting (IQR)
More informationNational Patient Safety Goals & Quality Measures CY 2017
National Patient Safety Goals & Quality Measures CY 2017 General Clinical Orientation 2017 January National Patient Safety Goals 1. Identify Patients Correctly 2. Improve Staff Communication 3. Use Medications
More informationBetter to Best Quality Excellence Achievement Awards. Recognizing Illinois Hospitals Leading in Quality and Innovation COMPENDIUM
Better to Best 2011 Quality Excellence Achievement Awards COMPENDIUM Recognizing Illinois Hospitals Leading in Quality and Innovation 2011 Quality Excellence Achievement Awards Overview IHA s Quality Care
More informationWHY IMPLEMENT CENTRAL LINE INSERTION BUNDLES
WHY IMPLEMENT CENTRAL LINE INSERTION BUNDLES WHY IMPLEMENT A CENTRAL LINE BUNDLE? Hospital-acquired infections (HAIs) are the fourth largest killer in America. The death toll from HAIs is estimated at
More informationClinical Documentation: Beyond The Financials Cheryll A. Rogers, RHIA, CDIP, CCDS, CCS Senior Inpatient Consultant 3M HIS Consulting Services
Clinical Documentation: Beyond The Financials Cheryll A. Rogers, RHIA, CDIP, CCDS, CCS Senior Inpatient Consultant 3M HIS Consulting Services Clinical Documentation: Beyond The Financials Key Points of
More informationOHA HEN 2.0 Partnership for Patients Letter of Commitment
OHA HEN 2.0 Partnership for Patients Letter of Commitment To: Re: Request to Participate in the Ohio Hospital Association Hospital Engagement Contract Date: September 24, 2015 We have reviewed the information
More informationAugust 1, 2012 (202) CMS makes changes to improve quality of care during hospital inpatient stays
DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Room 352-G 200 Independence Avenue, SW Washington, DC 20201 FACT SHEET FOR IMMEDIATE RELEASE Contact: CMS Media Relations
More informationImproving quality of care during inpatient hospital stays
DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Room 352-G 200 Independence Avenue, SW Washington, DC 20201 Office of Communications FACT SHEET FOR IMMEDIATE RELEASE Contact:
More informationWhy Shepherd? Shepherd Center Patients. Here s How We Measure Up: Shepherd Patient Population
Center Patients Total Patients ABI Patients SCI Patients Other Patients Center specializes in medical treatment, research and rehabilitation for people with spinal cord and brain injury. In CY, had 911
More informationHow Data-Driven Safety Culture Changes Can Lower HAC Rates
How Data-Driven Safety Culture Changes Can Lower HAC Rates Session #226, February 23, 2017 Holly O Brien & Abby Dexter Children s Hospital of Wisconsin 1 Speaker Introduction Holly O Brien, MSN RN Safety
More informationHospital Acquired Conditions: using ACS-NSQIP to drive performance. J Michael Henderson Jackie Matthews Nirav Vakharia
Hospital Acquired Conditions: using ACS-NSQIP to drive performance J Michael Henderson Jackie Matthews Nirav Vakharia Your Team: Quality & Patient Safety Institute Cleveland Clinic Mike Henderson: Chief
More informationReimbursement Policy Subject: Present on Admission Indicator for Health Care-Acquired Conditions 06/01/12 05/02/16 Administration Policy
Reimbursement Policy Subject: Present on Admission Indicator for Health Care-Acquired Conditions Committee Approval Obtained: Section: Effective Date: 06/01/12 05/02/16 Administration *****The most current
More information2016 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.
To Err Is Human: CDI Impact on Patient Safety Indicators Kathleen Shindle, RN, BSN, CCDS, CDIP Allison Clerval, RN, BSN, CCDS, CDIP Clinical Supervisors Thomas Jefferson University Hospital Philadelphia,
More information1. Nurses may remove non-tunneled catheters upon the order of a physician. Physicians remove tunneled catheters.
Removal of Non-Tunneled Central Venous Catheter (CVC) (Approved Aug 15, 2011/Rev Dec 16, 2011/Rev Jun 13, 2012) Vascular Access Guideline Table of Contents This procedure is posted on the BC Provincial
More informationJoint Commission NPSG 7: 2011 Update and 2012 Preview
Joint Commission NPSG 7: 2011 Update and 2012 Preview Pharmacy OneSource Webinar June 1, 2011 Louise M. Kuhny, RN, MPH, MBA, CIC The Joint Commission Objectives Upon completion of this program, participants
More informationPharmacy Round Table Tuesday, August 20, 2013
Florida Hospital Association Hospital Engagement Network (HEN) Pharmacy Round Table Tuesday, August 20, 2013 Audio for today s presentation is broadcast via phone access only: Please Dial-in - 866.740.1260
More informationSafety Grade Review Instructions SPRING 2018 SAFETY GRADE REVIEW PERIOD (FEBRUARY 20 MARCH 9, 2018)
Safety Grade Review Instructions SPRING 2018 SAFETY GRADE REVIEW PERIOD (FEBRUARY 20 MARCH 9, 2018) CONTENTS GET STARTED... 2 COMPLETE THE REVIEW PROCESS... 3 HOSPITAL SOURCE DATA... 3 LEAPFROG HOSPITAL
More informationHospital Acquired Conditions. Tracy Blair MSN, RN
Hospital Acquired Conditions Tracy Blair MSN, RN A hospitalacquired infection (HAI), also known as a nosocomial infection, is an infection that is acquired in a hospital or other health care facility Hospital
More informationMedicare Value Based Purchasing August 14, 2012
Medicare Value Based Purchasing August 14, 2012 Wes Champion Senior Vice President Premier Performance Partners Copyright 2012 PREMIER INC, ALL RIGHTS RESERVED Premier is the nation s largest healthcare
More informationNew York State Perinatal Quality Collaborative (NYSPQC): Improving Perinatal Health through Partnerships and Collaboration
New York State Perinatal Quality Collaborative (NYSPQC): Improving Perinatal Health through Partnerships and Collaboration Marilyn Kacica, MD, MPH Kristen Farina, MS New York State Department of Health
More information(1) Provides a brief overview of CMS Medicare payment policy for selected HACs;
DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850 Center for Medicaid and State Operations SMDL #08-004
More informationReimbursement Policy Subject: Present on Admission Indicator for Health Care-Acquired Conditions 01/01/14 Administration 05/02/16
Anthem BlueCross BlueShield Medicaid Reimbursement Policy Subject: Committee Approval Obtained: Effective Date: 01/01/14 Section: Administration 05/02/16 ***** The most current version of our reimbursement
More informationPartnership for Patients The Innovation Center Perspective
Partnership for Patients The Innovation Center Perspective Dodjie B. Guioa, MBA Hospital/ASC Program Lead Division of Survey & Certification CMS Region VI Thank You We re ready as never before to create
More information2014 Partnership in Prevention Award. November 21, :00-1:00PM EST. Introduction
2014 Partnership in Prevention Award November 21, 2014 12:00-1:00PM EST Introduction Don Wright, MD, MPH Deputy Assistant Secretary for Health (Disease Prevention and Health Promotion) U.S. Department
More informationPatient Experience of Care Survey Results Hospital Consumer Assessment of Healthcare Providers and Systems (Inpatient)
Patient Experience of Care Survey Results Hospital Consumer Assessment of Healthcare Providers and Systems (Inpatient) HCAHPS QUESTION DESCRIPTION (April 2016 - March 2017) Patients who reported that their
More informationHIMSS Davies Enterprise Application --- COVER PAGE ---
HIMSS Davies Enterprise Application --- COVER PAGE --- Applicant Organization: Hawai i Pacific Health Organization s Address: 55 Merchant Street, 27 th Floor, Honolulu, Hawai i 96813 Submitter s Name:
More informationThe 5 W s of the CMS Core Quality Process and Outcome Measures
The 5 W s of the CMS Core Quality Process and Outcome Measures Understanding the process and the expectations Developed by Kathy Wonderly RN,BSPA, CPHQ Performance Improvement Coordinator Developed : September
More informationNational Provider Call: Hospital Value-Based Purchasing
National Provider Call: Hospital Value-Based Purchasing Fiscal Year 2015 Overview for Beneficiaries, Providers, and Stakeholders Centers for Medicare & Medicaid Services 1 March 14, 2013 Medicare Learning
More informationCLABSI Prevention Hardwiring Improvement
CLABSI Prevention Hardwiring Improvement Brian Koll MD, FACP, FIDSA Executive Director, Infection Prevention Mount Sinai Health System Professor of Medicine, Icahn School of Medicine September 29, 2014
More informationAmbitious Goals to Reduce Harm: Why Has Progress Been Slow and What Can We Do to Bend the Curve?
Ambitious Goals to Reduce Harm: Why Has Progress Been Slow and What Can We Do to Bend the Curve? Don Goldmann, M.D. Senior Vice President Institute for Healthcare Improvement Professor of Pediatrics Harvard
More informationPreventing Hospital-Acquired Infections: A National Survey of Practices Reported by U.S. Hospitals in 2005 and 2009
Preventing Hospital-Acquired Infections: A National Survey of Practices Reported by U.S. Hospitals in 2005 and 2009 Sarah L. Krein, PhD, RN 1,2,3, Christine P. Kowalski, MPH 1,3, Timothy P. Hofer, MD,
More informationWelcome and Instructions
Welcome and Instructions For audio, join by telephone at 877-594-8353, participant code 56350822# Your line is OPEN. Please do not use the hold feature on your phone but do mute your line by dialing *6.
More informationValue-Based Purchasing & Payment Reform How Will It Affect You?
Value-Based Purchasing & Payment Reform How Will It Affect You? HFAP Webinar September 21, 2012 Nell Buhlman, MBA VP, Product Strategy Click to view recording. Agenda Payment Reform Landscape Current &
More informationReimbursement Policy Subject: Present on Admission Indicator for Health Care-Acquired Conditions 04/01/14 Administration 05/02/16
Reimbursement Policy Subject: Present on Admission Indicator for Health Care-Acquired Conditions Committee Approval Obtained: Effective Date: 04/01/14 Section: Administration 05/02/16 ***** The most current
More informationHospitals Face Challenges Implementing Evidence-Based Practices
United States Government Accountability Office Report to Congressional Requesters February 2016 PATIENT SAFETY Hospitals Face Challenges Implementing Evidence-Based Practices GAO-16-308 February 2016 PATIENT
More informationNew Strategies in Value Based Care
New Strategies in Value Based Care D. Keith Fernandez, M.D. Chief Clinical Officer, Privia Health CEO, Privia Medical Group Gulf Coast 713-545-1366 kfernandez@priviahealth.com none Disclosures Learning
More informationTranslating Evidence to Safer Care
Translating Evidence to Safer Care Patient Safety Research Introductory Course Session 7 Albert W Wu, MD, MPH Former Senior Adviser, WHO Professor of Health Policy & Management, Johns Hopkins Bloomberg
More informationSubject: Hospital-Acquired Conditions (Page 1 of 5)
Subject: Hospital-Acquired Conditions (Page 1 of 5) Objective: I. To facilitate safe patient care for all Health Share/Tuality Health Alliance (THA) members. II. To encourage and support provider efforts
More informationSafety Grade Review Instructions FALL 2018 SAFETY GRADE REVIEW PERIOD ( SEPTEMBER 18 OCTOBER 8, 2018)
Safety Grade Review Instructions FALL 2018 SAFETY GRADE REVIEW PERIOD ( SEPTEMBER 18 OCTOBER 8, 2018) CONTENTS Get Started... 2 Complete the Review Process... 3 Hospital Source Data... 3 Leapfrog Hospital
More informationSepsis Reduction through Technology and Process Improvements
Sepsis Reduction through Technology and Process Improvements Session #36, March 6, 2018 Amanda Logue, MD, Chief Medical Informatics Office, LGH Taylor Hargrave, BSN, RN, CIC, Infection Prevention Supervisor,
More informationPatricia Church, MSN, RN, PCNS-BC, CPON Bernice Mowery, PhD, PNP, RN
Beyond the Bundle: Strategies to Prevent Catheter Related Blood Stream Infections in a Pediatric Oncology In- Patient Unit Patricia Church, MSN, RN, PCNS-BC, CPON Bernice Mowery, PhD, PNP, RN Objectives
More informationOverview of Final Rule for FY 2011 Revisions to the Medicare Hospital Inpatient Prospective Payment System
Overview of Final Rule for FY 2011 Revisions to the Medicare Hospital Inpatient Prospective Payment System The final rule regarding fiscal year (FY) 2011 revisions to the Medicare hospital inpatient prospective
More informationOVERVIEW OF THE SPRING 2018 LEAPFROG HOSPITAL SAFETY GRADE
OVERVIEW OF THE SPRING 2018 LEAPFROG HOSPITAL SAFETY GRADE February 26, 2018 Missy Danforth Vice President of Health Care Ratings, The Leapfrog Group Presentation Overview 2 About the Leapfrog Hospital
More informationAccreditation, Quality, Risk & Patient Safety
Accreditation, Quality, Risk & Patient Safety Accreditation The Joint Commission (TJC) Centers for Medicare & Medicaid Services (CMS) Wyoming Department of Health (DOH) Joint Commission: - Joint Commission
More information2014 Inova Fairfax Medical Campus Quality Report
2014 Inova Fairfax Medical Campus Quality Report Overview Inova Fairfax Medical Campus is comprised of Inova Fairfax Hospital and Inova Children s Hospital. Inova Fairfax Hospital is a top-rated tertiary
More informationOutline 1. Infection Prevention Program Bloodborne Pathogens/Exposure Prevention & Management Standard Precautions 2. Hand Hygiene 3. Isolation Precau
Erlanger Infection Prevention Resident and df Fellow Orientation June 2011 1 Outline 1. Infection Prevention Program Bloodborne Pathogens/Exposure Prevention & Management Standard Precautions 2. Hand Hygiene
More informationThe Nurse s Role in Preventing CLABSI
The Nurse s Role in Preventing CLABSI This course has been awarded one (1.0) contact hour. This course expires on February 28, 2020 Copyright 2017 by RN.com. All Rights Reserved. Reproduction and distribution
More informationReducing Infections and Improving Engagement St. Luke's Nephrology Associates. Contact Information: Robert Gayner, M.D., FASN
BEST PRACTICES Vascular Access and CLABSI Reduction Reducing Infections and Improving Engagement St. Luke's Nephrology Associates Contact Information: Robert Gayner, M.D., FASN St. Luke's Nephrology Associates
More informationPreventing ICU Complications. Lee-lynn Chen, MD Assistant Clinical Professor UCSF Department of Anesthesia and Perioperative Care
Preventing ICU Complications Lee-lynn Chen, MD Assistant Clinical Professor UCSF Department of Anesthesia and Perioperative Care Overview Catheter related bloodstream infection Ventilator associated pneumonia
More informationOverview of the Spring 2016 Hospital Safety Score March 7, Missy Danforth, Vice President of Hospital Ratings, The Leapfrog Group
Overview of the Spring 2016 Hospital Safety Score March 7, 2016 Missy Danforth, Vice President of Hospital Ratings, The Leapfrog Group Presentation Overview Who is getting a Hospital Safety Score? Scoring
More informationUsing Care Bundles to Reduce Catheter Associated Blood Stream Infections in the NICU. Dr David Ng Paediatric Medical Officer Sarawak General Hospital
Using Care Bundles to Reduce Catheter Associated Blood Stream Infections in the NICU Dr David Ng Paediatric Medical Officer Sarawak General Hospital Outline of Presentation Introduction Definition of CABSI
More informationOverview of the Hospital Safety Score September 24, Missy Danforth, Senior Director of Hospital Ratings, The Leapfrog Group
Overview of the Hospital Safety Score September 24, 2013 Missy Danforth, Senior Director of Hospital Ratings, The Leapfrog Group Presentation Overview Who is getting a Hospital Safety Score? Changes to
More informationImpacting Quality Initiatives through Documentation Improvement. Fran Jurcak, MSN, RN, CCDS Vice President of Clinical Innovation Iodine Software
Impacting Quality Initiatives through Documentation Improvement Fran Jurcak, MSN, RN, CCDS Vice President of Clinical Innovation Iodine Software Objectives The learner will be able to: Articulate the goals
More informationInfection Prevention. Fundamentals of. March 21-23, 2017 Oregon Medical Association Portland, OR. oregonpatientsafety.org
Fundamentals of Infection Prevention A Comprehensive Training Course for Infection Prevention Professionals March 21-23, 2017 Oregon Medical Association Portland, OR oregonpatientsafety.org Course Information
More informationPerformance Scorecard 2013
NORTHWESTERN LAKE FOREST HOSPITAL Performance Scorecard 2013 updated May 2013 Northwestern Lake Forest Hospital is committed to providing the communities we serve the highest quality health care through
More informationIdentify patients with Active Surveillance Cultures (ASC)
MRSA CHANGE STRATEGIES The following tables include change strategies proven to be effective in healthcare settings. Implementing these changes through current or new processes may result in reducing healthcare
More informationAdditional Considerations for SQRMS 2018 Measure Recommendations
Additional Considerations for SQRMS 2018 Measure Recommendations HCAHPS The Hospital Consumer Assessments of Healthcare Providers and Systems (HCAHPS) is a requirement of MBQIP for CAHs and therefore a
More informationIn 2006 the Memorial Hermann Health System (MHHS)
2012 John M. Eisenberg Patient Safety and Quality Awards Memorial Hermann: High Reliability from Board to Bedside Innovation in Patient Safety and Quality at the National Level M. Michael Shabot, MD, FACS;
More informationNMSA Hospital-Acquired Infection
NMSA 1978 24-29 Hospital-Acquired Infection Table of Contents NMSA 1978 24-29 Hospital-Acquired Infection... 1 24-29-1. Short title.... 2 24-29-2. Definitions.... 2 24-29-3. Advisory committee created;
More informationHEN 2.0 CLABSI WEBINAR NAILING CLABSI PREVENTION! February 11, :00 a.m. 12:30 p.m. CT
HEN 2.0 CLABSI WEBINAR NAILING CLABSI PREVENTION! February 11, 2016 11:00 a.m. 12:30 p.m. CT 1 WELCOME AND INTRODUCTIONS Kimberly King, Program Specialist, HRET 11:00 11:05 2 WEBINAR PLATFORM QUICK REFERENCE
More informationCME Disclosure. HCAHPS- Hardwiring Your Hospital for Pay-for-Performance Success. Accreditation Statement. Designation of Credit.
CME Disclosure Accreditation Statement Studer Group is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. Designation
More informationSurgeon Champion: Getting Started, What You Need to Know
Surgeon Champion: Getting Started, What You Need to Know Ninh T. Nguyen, MD, FACS Professor of Surgery Surgeon Champion Vice-Chair, Dept Surgery University of California, Irvine, Medical Center, Orange,
More informationHealthcare-Associated Infections: State Plans
Healthcare-Associated Infections: State Plans Department of Health & Human Services Office of the Secretary Office of Public Health & Science Web Conference Wednesday, August 19, 2009 Goals Provide background
More informationP4P Programs 9/13/2013. Medicare P4P Programs. Medicaid P4P Programs
P4P Programs Medicare P4P Programs Hospital Quality Reporting Programs (IQR and OQR) Hospital Value-Based Purchasing (VBP) Program Hospital Readmissions Reduction Program (HRRP) Hospital-Acquired Conditions
More informationThe dawn of hospital pay for quality has arrived. Hospitals have been reporting
Value-based purchasing SCIP measures to weigh in Medicare pay starting in 2013 The dawn of hospital pay for quality has arrived. Hospitals have been reporting Surgical Care Improvement Project (SCIP) measures
More informationAppendix A: Encyclopedia of Measures (EOM)
Appendix A: Encyclopedia of Measures (EOM) Great Lakes Partners for Patients HIIN Hospital Improvement Innovation Network (HIIN) Program Evaluation Measures Adapted from Version 1.0 AHA/HRET HEN 2.0 HIIN
More informationSTANDARDIZED PROCEDURE CENTRAL LINE PLACEMENT and TEMPORARY NONTUNNELLED CENTRAL VENOUS DIALYSIS CATHETER INSERTION (Adult, Peds)
I. Definition: This protocol covers the task of central (venous) catheter placement and temporary nontunnelled central venous dialysis catheters by the Advanced Health Practitioner. The purpose of this
More informationReconciling Abstracted to Electronic Quality Measures
Reconciling Abstracted to Electronic Quality Measures Tuesday, March 1, 2016 Keith F. Woeltje, PhD, MD, VP and Chief Medical Information Officer BJC HealthCare Center for Clinical Excellence Liz Richard,
More informationInpatient Quality Reporting Program
Hospital Value-Based Purchasing Program: Overview of FY 2017 Questions & Answers Moderator: Deb Price, PhD, MEd Educational Coordinator, Inpatient Program SC, HSAG Speaker(s): Bethany Wheeler, BS HVBP
More informationNew federal safety data enables solutions to reduce infection rates
Article originally appeared in Modern Healthcare April 15, 2017 New federal safety data enables solutions to reduce infection rates New CDC initiative enables facilities to pinpoint hot spots and develop
More informationImpact of Hospital-Acquired Conditions and NQF Safe Practices
TMIT National Test Bed Work Shop: Impact of Hospital-Acquired Conditions and NQF Safe Practices CEO s Meet Your Revenue Preservation Officer Your PSO Charles Denham MD September 4, 2008 2008 TMIT 1 2 NQF
More informationLightning Overview: Infection Control
Lightning Overview: Infection Control Gary Preston, PhD, CIC, FSHEA Terry Caton, CIC Carla Ward, CIC 2012 Healthcare Management Alternatives, Inc. Objectives At the end of this module you will know: How
More informationGoal Elements of Performance APIC Comments APIC Recommendations
Association for Professionals in Infection Control and Epidemiology, Inc. Comments on the Joint Commission s Proposed 2012 National Patient Safety Goals The Joint Commission Practice Guidance Team Accreditation
More informationOur Journey Towards CAUTI Freedom. Johnson City Medical Center
Our Journey Towards CAUTI Freedom Johnson City Medical Center Objectives List two of the HICPAC appropriate indications for indwelling urinary catheters List two obstacles we encountered that prevented
More informationPOLICIES AND PROCEDURE MANUAL
POLICIES AND PROCEDURE MANUAL Policy: MP209 Section: Medical Benefit Policy Subject: Medical Error Never Events, Hospital Acquired Conditions, and Hospital Readmission Review I. Policy: Medical Error Never
More informationMinnesota Statewide Quality Reporting and Measurement System: Appendices to Minnesota Administrative Rules, Chapter 4654
This document is made available electronically by the Minnesota Legislative Reference Library as part of an ongoing digital archiving project. http://www.leg.state.mn.us/lrl/lrl.asp Minnesota Statewide
More informationConsumers Union/Safe Patient Project Page 1 of 7
Improving Hospital and Patient Safety: An overview of recently passed legislation and requirements towards improving the safety of California s hospital patients June 2009 Background Since 2006 several
More informationMEASURE APPLICATIONS PARTNERSHIP Safety and Care Coordination Task Force Convened by the National Quality Forum. Meeting Summary June 19-20, 2012
MEASURE APPLICATIONS PARTNERSHIP Safety and Care Coordination Task Force Convened by the National Quality Forum Meeting Summary June 19-20, 2012 An in-person meeting of the Measure Applications Partnership
More informationPhysician Performance Analytics: A Key to Cost Savings
Physician Performance Analytics: A Key to Cost Savings Session #90, February 21, 2017 Jim Gera, SVP of Business Development, Signature Medical Group, Inc. 1 Speaker Introduction Jim Gera, MBA SVP of Business
More informationIowa Healthcare Collaborative - HEN 2.0 Measures
Iowa Healthcare Collaborative - HEN 2.0 Measures Yellow Pink Purple Green Blue Legend Readmissions and Care Transitions Healthcare-associated Infections Hospital Acquired Conditions Safety Across the Board
More informationF E B R U A R Y 2 8, S C O T T F L A N D E R S, M D V I N E E T C H O P R A, M D
PICC Tier 1 Interventions Webinar F E B R U A R Y 2 8, 2 0 1 7 S C O T T F L A N D E R S, M D V I N E E T C H O P R A, M D Agenda HMS Performance & 2- Tiered Approach (5 minutes) Review PICC Tier 1 Interventions
More information