HOSPITAL IMPROVEMENT INNOVATION NETWORK (HIIN) Jessica Stultz, Director of Clinical Quality May 23, 2017

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1 HOSPITAL IMPROVEMENT INNOVATION NETWORK (HIIN) Jessica Stultz, Director of Clinical Quality May 23, 2017

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3 Great things are happening! Hospital milestone 4 achievement Total 91.8% or 67 HIIN hospitals Earn $475 $31,825 will be sent out in July 2017

4 What is the Stipend Breakdown? Data Due Date Milestone 4 May 8, 2017 Milestone 5 Sept. 14, 2017 Milestone 6 Jan. 19, 2018 Milestone 7 June 11, 2018 Milestone 8 Aug. 21, 2018 Amount When is $ dispersed Criteria $475 July 2017 Hospitals submit 85 percent or greater of their applicable required data (must include core* and readmission measures) $1450 Nov Hospitals submit 85 percent or greater of their applicable required data (must include core* and readmission measures) AND must meet Year 1 goals on readmission AND seven other topics.** Hospitals that do not meet Milestone 4 will NOT be eligible for Milestone 5 $475 Mar Hospitals submit 85 percent or greater of their applicable required data (must include core* and readmission measures) - - Hospitals submit 85 percent or greater of their applicable required data (must include core* and readmission measures) $1525 Sept Hospitals submit 85 percent or greater of their applicable required data (must include core* and readmission measures) AND must meet Year 2 goals on readmission AND seven other topics.** Hospitals that do not meet Milestone 6 AND 7 will NOT be eligible for Milestone 8 * Core measures are as defined by HRET and subject to change per milestone. As of 3/28/2017 HRET has not defined these core measures. **Maintaining zero meets goal *There will not be separate educational reimbursements in the HIIN.

5 What is the Stipend Breakdown? Data Due Date Milestone 4 May 8, 2017 Milestone 5 Sept. 14, 2017 Milestone 6 Jan. 19, 2018 Milestone 7 June 11, 2018 Milestone 8 Aug. 21, 2018 Amount When is $ dispersed Criteria $475 July 2017 Hospitals submit 85 percent or greater of their applicable required data (must include core* and readmission measures) $1450 Nov Hospitals submit 85 percent or greater of their applicable required data (must include core* and readmission measures) AND must meet Year 1 goals on readmission AND seven other topics.** Hospitals that do not meet Milestone 4 will NOT be eligible for Milestone 5 $475 Mar Hospitals submit 85 percent or greater of their applicable required data (must include core* and readmission measures) - - Hospitals submit 85 percent or greater of their applicable required data (must include core* and readmission measures) $1525 Sept Hospitals submit 85 percent or greater of their applicable required data (must include core* and readmission measures) AND must meet Year 2 goals on readmission AND seven other topics.** Hospitals that do not meet Milestone 6 AND 7 will NOT be eligible for Milestone 8 * Core measures are as defined by HRET and subject to change per milestone. As of 3/28/2017 HRET has not defined these core measures. **Maintaining zero meets goal *There will not be separate educational reimbursements in the HIIN.

6 HIIN Executive Dashboard Timeline Preview Period 5/30 6/6 CEO send out 6/8

7 Data Due Dates HIIN Project Year 1 HIIN Data Due Dates Task Deadline For Hospital to Submit Data Data Included in Deadline Baseline 17-Jan Baseline Monthly Monitoring Data 23-Jan Oct-Dec Monthly Monitoring Data 20-Feb Oct-Jan Mid-Year Report 8-Mar Oct-Jan Monthly Monitoring Data 23-Mar Oct-Feb Monthly Monitoring Data 20-Apr Oct-March Milestone 4 8-May Hard deadline for ALL data Oct-Feb Monthly Monitoring Data 22-May Oct-April Monthly Monitoring Data 22-Jun Oct-May Monthly Monitoring Data 21-Jul Oct-June Monthly Monitoring Data 23-Aug Oct-July Target Report 6-Sep Oct-July Monthly Monitoring Data 19-Sep Oct-Aug Milestone 5 14-Sep Hard deadline for ALL data Oct-May Monthly Monitoring Data 23-Oct Oct-Sept

8 Up Campaign

9 UP Campaign Two Foundational Questions: Is my patient awake enough to get up? Have I protected my patient against infections?

10 The Way UP: Deep Dive into WAKE UP May 23, 2017 Betsy Lee, MSPH, RN Cynosure Health

11 The Way UP

12 Why the UP Campaign? Increases impact on harm reduction Generates momentum in your organization Focuses support from leadership Engages front line staff connects the dots creates a vision Applies throughout organization Simplifies patient safety implementation Help patients recover faster and with fewer complications

13 Can we streamline and simplify making it easier for front-line staff and still improve safety?

14 Objectives Review the three UP Campaign crosscutting interventions Identify essential next steps for WAKE UP Discuss messaging for the UP Campaign for your facility

15 # 1 Opioid & Sedation Management ADE Failure to Rescue Delirium Falls Airway Safety VTE VAE W A K E - UP

16 # 2 Early Progressive Mobility Falls PrU Delirium CAUTI VAE VTE Readmissions G E T - U P

17 # 3 Hand Hygiene CDI CAUTI SSI VAE CLABSI Sepsis MDRO S O A P - U P

18 FOUNDATIONAL QUESTIONS: 1. Is my patient awake enough to get up? 2. Have I protected my patient from infections?

19 # 1 Opioid & Sedation Management ADE FTR Delirium Falls AS VTE VAE W A K E - UP

20 Sleep vs Sedation

21 Not Just Sedatives and Opioids Antihistamines/anticholinergics Antipsychotics Some antidepressants Anti-emetics Muscle relaxants

22 ICU Pitfalls of Sedatives and Analgesics Sedatives and analgesics may contribute to: Increased duration of mechanical ventilation Length of intensive care requirement Impede neurological examination May predispose to delirium Kollef M, et al. Chest. 114: Pandharipande et al. Anesthesiology. 2006;124:21-26.

23 Med/Surg Pitfalls of Sedatives and Analgesics Over sedation Transfer to ICU Hypoxic encephalopathy Death

24 MUST DO's

25 WAKE-UP MUST DO's 1. Establish Expectations 2. Pair POSS & Pain 3. Manage with Multiple Modalities

26 MUST DO #1 Establish Expectations Goals of Pain Management: Relieve suffering Achieve early mobilization Reduce hospital length of stay THE GOAL IS NOT ZERO PAIN! 26

27 MUST DO #2 Pair POSS & Pain Just Right! Over Medicated: Hibernating Under Medicated: Not Happy 27

28 POSS AKA GOLDILOCKS SCALE S- Sleep, easy to arouse 1- awake and alert 2- slightly drowsy 3- frequently drowsy, drifts off to sleep during conversation 4- somnolent, minimal or no response to stimulation 28

29 No discharge from PACU No additional opioids S = Sleep, easy to arouse Acceptable; no action necessary; may increase opioid dose if needed 1 = Awake and alert Acceptable; no action necessary; may increase opioid dose if needed 2 = Slightly drowsy, easily aroused Acceptable; no action necessary; may increase opioid dose if needed 3 = Frequently drowsy, arousable, drifts off to sleep during conversation Unacceptable; monitor respiratory status and sedation level closely until sedation level is stable at less than 3 and respiratory status is satisfactory; decrease opioid dose 25% to 50% 1 or notify primary 2 or anesthesia provider for orders; consider administering a non-sedating, opioid-sparing nonopioid, such as acetaminophen or a NSAID, if not contraindicated; ask patient to take deep breaths every minutes. 4 = Somnolent, minimal or no response to verbal and physical stimulation Unacceptable; stop opioid; consider administering naloxone 3,4 ; stay with patient, stimulate, and support respiration as indicated by patient status; call Rapid Response Team (Code Blue) if indicated; notify primary 2 or anesthesia provider; monitor respiratory status and sedation level closely until sedation level is stable at less than 3 and respiratory status is satisfactory. *Appropriate action is given in italics at each level of sedation. 1 If opioid analgesic orders or hospital protocol do not include the expectation that the opioid dose will be decreased if a patient is excessively sedated, such orders should be promptly obtained. 2 For example, the physician, nurse practitioner, advanced practice nurse, or physician assistant responsible for the pain management prescription. 3 For adults experiencing respiratory depression give intravenous naloxone very slowly while observing patient response ( titrate to effect ). If sedation and respiratory depression occurs during administration of transdermal fentanyl, remove the patch; if naloxone is necessary, treatment will be needed for a prolonged period, and the typical approach involves a naloxone infusion. Patient must be monitored closely for at least 24 hours after discontinuation of the transdermal fentanyl. 4 Hospital protocols should include the expectation that a nurse will administer naloxone to any patient suspected of having life-threatening opioid-induced sedation and respiratory depression. 1994, Pasero C. Used with permission. As cited in Pasero C, McCaffery M. Pain Assessment and Pharmacologic Management, p St. Louis, Mosby/Elsevier,

30 Two Scales are Better than One for Narcotic and Sedation Administration PAIN ALONE Risk factors may be absent Objective? Dosage based on number or range Patients and families understand the numeric dosing PAIN & POSS Two scales allow for safer dosing High pain scale with high POSS scale no narcotics High pain scale low POSS - med dose 30

31 MUST DO #3 Multi-Modal Pain Management Pharmacological and Non-pharmacological 31

32 MULTIMODAL PAIN MANAGEMENT Combination of opioid and one or more other drugs acetaminophen (Tylenol, others) ibuprofen (Advil, Motrin IB, others) celecoxib (Celebrex) ketamine (Ketalar) gabapentin (Gralise, Neurontin) Non-pharmacological interventions 32

33 CAN WE MANAGE PAIN WITH NON- PHARMACOLOGIC METHODS? What do we do at home? Comfort measures: Pet therapy Warm compresses, blankets Ice packs Extra pillows Aromatherapy Massage Herbal tea Stress ball Music 33

34 DO COMFORT ITEMS HELP? These modalities can: Reduce anxiety Reduce pain Reducing anxiety can reduce pain Non-pharmacologic pain reduction methods reduce the need for pain medications 34

35 DO HOSPITALS OFFER THESE? ervices_amenities/services/pain-control-comfort-menu.html 35

36 POSITIVE RESULTS Pain scores Nausea scores Anxiety scores. All decreased by more than 50% NEXT: Looking to see if opioid usage and opioid ADEs are both decreased. 36

37 CHECK POINT 37

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40 Betsy Lee, MSPH, RN Improvement Advisor Cynosure Health 40

41 Projects Coming Soon

42 Qualaris Audit Tool Intents to participate May 5 Hand Hygiene 8 Culture of Safety Rounding 10 Sepsis 10 Readmissions 8

43 Do Your Physicians Participate in Quality Improvement? PHYSICIAN INCLUSION OPPORTUNITIES ABMS MOC Part IV Final touches are putting put on the ABMS MOC Part IV communication that will go out on soon. We are excited to be able to offer this opportunity to many physicians that work on QI projects on HIIN! Adaptive Leadership HRET is excited to announce that the Adaptive Leadership in Medicine training will be held in Chicago this August (dates will be announced shortly). This is an opportunity for a physician and administrator from the same organization to join together and gain invaluable leadership tools. HIIN hospitals are eligible to receive a scholarship that includes the training, hotel and airfare free of charge. Non-HIIN hospitals are also encouraged to apply, but please note that their scholarship includes only the cost of the training. Those interested in applying will be required at the time of registration to identify the individual from their organization who will be joining them. Details regarding the application process will follow shortly.

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45 Website Updates

46 Clinical Quality Initiatives

47 HIIN

48 Upcoming Events

49 MHA SQI Webinars What s Up Wednesdays 12 noon first Wednesday of each month Register here HIIN Huddles 2 p.m. fourth Tuesday of each month Register here

50 HRET Fishbowl Webinar HRET HIIN Readmissions Reduce Readmissions Fishbowl Series - Session One May 25, :00 a.m. - 12:00 p.m. CT Register here. Does your organization have an opportunity to gain new insights and test strategies to reduce readmissions? Join the HRET HIIN on May 25th for the first reducing readmissions "Fishbowl" event where you will watch the process improvement journey of five HRET HIIN hospitals. Listen in as the hospitals create reduction aim statements, focus on their target population and develop their first small test of change to implement in their readmissions reduction efforts.

51 HRET Webinars HRET HIIN Physician Virtual Event May 31, :00 a.m. - 12:00 p.m. CT Register here. HRET HIIN CDI Virtual Event June 1, :00 a.m. - 12:00 p.m. CT Register here.

52 Readmissions Immersion Project Enrollment June 2017 Project kick off August 15, 2017 Open to the first 20 participants New approach for collaboration throughout the project

53 Sepsis Immersion Project Enrollment October 2017 Project kick off November 29, 2017 Open to the first 20 participants New approach for collaboration throughout the project

54 Save the Date HIIN Annual Meeting (active HIIN hospitals will receive reimbursement for mileage and hotel) June 6-7 Courtyard by Marriott in Columbia, Mo. Topics: Culture of Safety and PFE Register here prior to May 23

55 Tuesday, June 6 12:30 p.m. Registration 1 p.m. Welcome and HIIN Project Overview (Data!) 1:30 p.m. Introduction to the Culture of Reliability Matthew Schreiber, M.D. Chief Clinical Officer, Newark Beth Israel Medical Center and Children s Hospital 3 p.m. Break 3:15 p.m. The Power of One: The Nurse and the Patient Safety Skill That Changed One Family s Life Forever Stephen W. Harden Chairman and CEO, Life Wings Partners LLC 5 p.m. Wrap Up 5:30 p.m. Adjournment Day One

56 Wednesday, June 7 7:30 a.m. Registration 8 a.m. Welcome and Recap 8:30 a.m. Readmissions: An Example of Preventable Harm Matthew Schreiber, M.D. 10 a.m. Break 11 a.m. Practical Strategies to Reduce Preventable Readmissions Matthew Schreiber, M.D. 1 p.m. Wrap Up 1:30 p.m. Adjournment Day Two

57 HIIN HAI Regional Bootcamps Cape Girardeau July 18 Ray s Banquet Center Register here Chesterfield July 19 Hampton Inn & Suites Register here Springfield August 24 Oasis Hotel Convention Center Register here Independence August 25 Hilton Garden Inn Register here

58 Bootcamp Agenda Content Topics (details and objectives coming soon) HIIN Project Update - data update, successes, opportunities TeamSTEPPS Hand Hygiene case studies HAI - Soap Up, Culture, HRO, PFE, Handoffs.etc. ASP project case studies HAI - Action Items and synthesis for sustainability Next Steps and plan for end of project year one - looking toward year two

59 Save the Date Excellence in Clinical Care Series September Lake Ozark, Mo Annual Emergency Preparedness & Safety Conference October Lake Ozark, Mo.

60 Resources

61 ListServ Get access to other hospitals, subject matter experts and other resources to avoid reinventing the wheel. Listserv sign up open through the duration of the HIIN Sign up today!

62 HIDI HealthStats Drug Deaths Increase Among Middle-Aged, White Missourians

63 Opioid Initiative

64 Date of Last Posters Updated topic-specific Date of Last posters now are available to download on the HRET HIIN website including 16 HIIN topics! This tool is designed to help track the date of the last adverse event at your facility. As an example see the date of last septic event poster to the left. Join your colleagues in reaching zero harms! Hard copies will be available at the conference in June or upon request.

65 Here are the change packages that have been recently created or updated. Change packages for Culture of Safety, Malnutrition and VTE will be available by the end of next week. Change packages for Diagnostic Error and Antibiotic Stewardship are in development and scheduled to be released in July. Adverse Drug Events Airway Safety Catheter-Associated Urinary Tract Infection C. difficile Infection Central Line-Associated Bloodstream Infection Delirium Exposure to Radiation Falls Multi-Drug Resistant Organisms Pressure Ulcers Readmissions Sepsis Surgical Site Infection Ventilator-Associated Event

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68 Missouri HIIN Team Jessica Stultz Amanda Keilholz Toi Wilde Mary Shackelford Jessica Stultz, RN, BSN, MHA, CPHQ Director of Clinical Quality 573/ , ext Amanda Keilholz HIIN Program Manager 573/ , ext Toi Wilde, RN, BSN, MBA HIIN Program Manager 573/ , ext Mary Shackelford, RN, BSN Subject Matter Expert