Nevada Hospital Engagement Network Monthly Report

Nevada Hospital Engagement Network Monthly Report April 9, 2013 Centers for Medicare & Medicaid Services Partnership for Patients Initiative

CONTRACT: HHSM-500-2012-00016C CONTRACTOR: Nevada Hospital Association (NHA) 5250 Neil Road, Suite 302 Reno, NV 89502 PROJECT MANAGER: Marissa Brown, MHA, BSN, RN 5250 Neil Rd. #302 Reno, NV 8950 Office: 775-827-0184 Email: marissa@nvha.net i

HIGH-LEVEL 30-DAY EXECUTIVE SUMMARY (Note: we have assigned random blinded letters and numbers to identify individual hospitals in our network in order to protect their facility-specific identification while still allowing an internal cross reference to the hospitals we are referencing in this report) SUCCESSES: With increased use of CHIA data, access to NHSN data and an increase in Self-Reporting, we are now able to report at a rate above the 60% threshold for 10 of our 11 HACs. Going forward, we have a commitment from the CHIA Administrator to consistently provide every 3-4 months so that the NV HEN can meet CMMI requirements Several HACS measures are showing improvement rates of 30% or greater with 60% or greater reporting: o EED has decreased 79% from a 2010 average benchmark with 67% of our facilities with OB Department s submitting data. o Falls with Injury has decreased 39% from the 2010 average benchmark with 91% of hospitals accounted for in the data. o For our facilities reporting into NHSN (74%), their SSI rate for colon surgeries decreased 35% between Q1 and Q4 2012. o Our VAP rate decreased 45% between Q1 2010 and Q3 2012 with 79% of our facilities accounted for in the data. o Self reported CLABSI rate has declined 32% from baseline with 70% reporting. Conducted Site Visits for 8 facilities used those visits to make modifications to our new Taking Stock tool which crosswalks the HEN Programs goals (HACs, Leadership, Patient Engagement, etc) to the actual strategies, successes and challenges each hospital faces. This tool will give us a more targeted perspective on how to assist our facilities and partner with them to spread and share solutions. ADE self-reported data collection metrics and methodologies were not producing participation results. During the 3/21/13 meeting of the ADE Advisory Committee, we have resolved the data lag issues by modifying the metrics and expect to see more data flow next month. We have identified 2 facilities which are showing excellent results in some of the ADE goals. We will be releasing their Success Stories as soon as we have consent to release their data. (See ADE Section for more details) NV HEN Weekly Newsletter initiated April 1. Provides concise HEN news, national PfP information and links and best-practice toolkits and testimonials. This is transmitted to our entire network, including leadership. Coordinating with Project ECHO Nevada (University of Nevada School of Medicine) to provide basic Microbiology training for clinical professionals in our rural setting who have difficulty traveling to live CE or releasing bulk staff for traditional classes. Project ECHO provides education via VTC tele-health link and records sessions for later review and CEU access. Currently in process to identify a resource for rural hospitals to provide on-going BI-LINGUAL Environmental Service Training. Because of distance and small staff numbers, they have identified the need for programming that can be recorded (as in Project ECHO) or provided in reproducible modules. Our goal is to have a joint planning and coordination session by latter April 2013. 1

HIGH-LEVEL 30-DAY EXECUTIVE SUMMARY AREAS FOR IMPROVEMENT: We will establish our cost and patient impact formula reference library to enable a consistent, documented approach to assigning impact value to analyses and success stories. Our Pressure Ulcer performance is below target. Our Pressure Ulcer Advisory Committee was convened and met in March to start the educational action plans and spread to be able to show results (See Pressure Ulcer Section for more information) Readmission data is not showing the expected improvement that is shown in other data measurement groups (QIO and Nevada Partnership for Value-Driven Healthcare). We are currently comparing and analyzing the variables between data sources to better understand the variances. VTE results are showing a 15% improvement rate (ALL discharges). Therefore, this is also an area for concentrated effort. We will convene a Task Force to help guide the best-practice (mechanical and pharmaceutical interventions) in June 2013. AHRQ VTE Toolkits were distributed in February 2013 to the facilities and it will take a few months to start seeing results. As we emphasize the mechanical interventions vs the pharmaceutical interventions, we may also have a positive effect on reducing ADE associated with Warfarin. We have invited AHRQ to speak at our April monthly teleconference on how to initiate the toolkit. Although our aggregate Falls with Injury data is showing improvement, 5 hospitals have requested assistance in this area. We are providing technical assistance through Touro University and also through sharing the AHRQ Falls toolkit and the NV HEN Success stories of how others have achieved improvement. Although we are showing improvement in Narcotics and Insulin monitors, we are still not at an acceptable participation level. We adjusted the required metrics for the month of March and expect to see more data participation in the next reporting period. The Warfarin/INR monitor appears to need the most concentrated effort. (See ADE section for more detail) CAUTI infection rates have improved slightly over 2011, but are showing a net increase over the 2010 baseline. This seems to be a national problem as well and we are analyzing data to understand and explain the reason(s) for the increase. In our own HEN, we are seeing a trend that the Long-Term Care and Rehab facilities seem to be showing the most dramatic increase and we will be focusing our technical assistance to those settings showing the most need especially those not enrolled in a CUSP CAUTI Cohort. We have two CUSP Cohorts, to which 14 of our hospitals are participants. 2

READMISSIONS Readmissions Report Method: CHIA % of Hospitals Reporting: 91% (31/34 hospitals) ANALYSIS OF CHIA DATA SET: CHIA All Payer 30 Day Readmissions data shows a 3.6% increase from the baseline of January 2010. With the exclusion of the acute care hospitals and non-medicare payers, we are realizing a 20% decrease in readmissions from the January 2010 baseline. We continue to explore why the LTACS, Rehabs and Medicare population are doing so much better than the acute care facilities and private insurance patients. Even though, the NV HEN readmissions rate is showing a slight increase, other measures of Nevada s readmission rate are showing reductions. The Nevada Partnership for Value-driven Healthcare (NPV) program is showing a 2% decrease for all payers and a 3% decrease in the Medicare population. National Coordinating Center for Care Transitions claims we have achieved a 5% decrease for Medicare beneficiaries. The NV Quality Improvement Organization (QIO) has data showing readmissions in Nevada are down 22% for the Medicare population. All 3 entities have different data analysis methods from the NV HEN. Efforts are currently underway to determine why the NV HEN are not seeing similar reductions. SUCCESSES: Because ADE is one of the leading causes of readmissions, ADE Advisory Group agreed in March 13 to prioritize the agenda item of standardizing the Medication Reconciliation Tool across the continuum. We will be partnering with the NV QIO to accomplish this goal as we both have stakeholders in our contracts that interact in this regard The HEN has been collaborating with the local QIO and its transitions of care work with nursing homes. The QIO has convened a workgroup of senior care providers and has invited our hospitals to participate in their work to improve care transitions. 3

WHAT WORKED: READMISSIONS Post-discharge phone calls to ensure patients are following up with their primary care physicians Collaboration with Home Health Nurse and Hospitalists during the first 15 days post discharge to receive orders until patients have been seen by their Primary Care Physician Teachback- to ensure patients understand discharge instructions Transitioning patients to Long Term Acute Care Facilities with Intensive Care Units Partnering with senior centers and Skilled Nursing Facilities to help educate seniors about medications Situation-Background-Assessment-Recommendations (SBAR) tool to improve communication with patients on discharge instructions Project Red (Re-Engineered Discharge) toolkit- to overhaul the discharge process and make communication and follow up with patients easier. HEN STRATEGIES TO MOVE TOWARDS A 20% REDUCTION: Organizing a Medication Reconciliation process and forms standardization collaborative that includes NV QIO/CCTP pilot and Transitions of Care models. This will allow us to bring many stakeholders to the table to work on common problems and solutions. (Projected to convene June 2013). We are trying to determine why we are still seeing an increase in readmissions at our acute care facilities and in the non-medicare population. Some of our hospitals have performed root cause analyses to help them plan future interventions. The Nevada HEN has an upcoming plenary session that will focus on readmissions. It will feature a physician from IHI who will give a presentation on strategies to reduce readmissions. The QIO will also present at this session on new best practices it has available or on the near horizon for reducing readmissions so that hospitals can act now to tap into those resources. The Nevada Quality Assurance (QA) Division is starting an RN intervention based on appeals calls. Although the patient may be clinically justified to be discharged, they often have other barriers to a successful transition (no family, access issues at home, medication costs, etc.) that is identified while fact-finding the appeal case. When these are identified the QA RN will call the facility to inform them of the potential problems so that the hospital can do a better job of discharge planning and facilitation. This intervention will be communicated to the hospitals with a 24-hour lead-time of discharge. The NV HEN will assist the NV QA in educating hospitals regarding the new process and it s utility to improve readmission rates. We are collaborating with the hospitals that are struggling with readmissions. It is our plan to assist them with new best practices and to give them a goal to show results by the end of the 3 rd quarter 2013. HOSPITAL STRATEGIES TO MOVE TOWARDS A 20% REDUCTION: Hospitals are also encouraged to attend the QIO s Care Transitions Learning and Action Networks. A few of our hospitals have recognized a problem with patients following up in a timely manner with their physicians. In response to this information, (Hospital Y) has opened a heart failure clinic. This clinic sees heart patients who can t see their primary care physician within 72 hours of their discharge. While the clinic has only been open since January of 2013, early data has shown that only 2 of 32 discharged heart patients have been readmitted since the program started. 4

ADVERSE DRUG EVENTS (ADE) Adverse Drug Events Report Method: Self-reported % of Hospitals Reporting: 38% (13/34 of hospitals) Report data for at least 1 of the ADE metrics SUCCESSES: We have accomplished an 86% relative decrease from baseline for adverse drug events involving insulin with 6 facilities reporting current data (within the past 6 months). We have accomplished an 11% relative decrease from baseline for adverse drug events involving injectable narcotics with 10 facilities reporting current data (within the past 6 months.) WHAT WORKED: Rural hospital (H) is showing a 54% decrease in injectable narcotic ADE and a 13% decrease in Insulin ADE. Upon interview with this facility, they indicated the following keys to their success were: o Update and clarification of the Insulin Protocol o Accucheck education and re-education provided to nursing staff o Ongoing education and re-education of staff about insulin properties and appropriate dosing. o Nurse check nurse dosing and administration of sliding scale insulin o Ongoing staff training for PCA pump setting and operation. o Re-education efforts in pain level evaluation and management with injectable narcotics Acute Care Facility (V) is showing a 31% decrease in prevention of ALL medication ADE. They attribute their success to a multi-pronged approach that started in November 2011. Their current action plan includes an intensive education and direct observation program on medication administration processes. They formed a Multidisciplinary Task Force (consisting of Physicians, Nurses, Pharmacists and Administration) who initially met weekly and now meet bi-monthly to evaluate the progress and challenges of medication administration. An independent Pharmacy Consultant was hired to help them take an impartial look at their system. 5

ADVERSE DRUG EVENTS (ADE) In Spring 2012, they implemented a bar-code driven medication process to validate the correct medication was added or removed from Automated dispensing and also developed and SBAR Nursing/Pharmacy communication tool to improve the accuracy and quality of interdepartmental communications. Their target for this summer is an implementation of their Electronic Medical Record, which will improve Medication Safety as it cross references to the patient-specific aspects and other safety-check monitoring parameters. Their data is shared at their Pharmacy & Therapeutics Committee, Performance Improvement Committee, Patient Safety, Med Exec and Governing Board. OPPORTUNITIES FOR IMPROVEMENT: Data is showing a 188% increase from baseline with 8 facilities reporting current data (within the past 6 months). One of these hospitals (H) is currently reviewing their data, as they believe it may be inaccurate. If they make corrections, we will retroactively correct our data set. We identified a recall of B-D Vacutainers, which caused potential elevated aptt values and subsequent dosing adjustment errors. This may explain the spike starting in the Fall of 2011. Our revised metrics for insulin and anticoagulants is expected to produce greater data response from facilities in next reporting period. HEN STRATEGIES TO MOVE TOWARDS A 40% REDUCTION AND INCREASE THE NUMBER OF HOSPITALS REPORTING DATA: Continue to convene the NV HEN ADE Advisory Committee to discuss challenges and strategies (Next meeting is May 2013). Work with HEN ADE Advisory Committee to correct order sets, hand-off communication tools and provide retraining on proper prescribing for hydrocodone (as per new reduced dosing guidelines) and to screen overall for dose-related errors. 3/21/13 ADE Advisory Committee agreed upon new metrics to improve ease of data collection and reporting. We will accept data in the original format so that hospitals who have been providing data up to this point can continue with their existing plan and will not have to go back and recalculate historic data. o We agreed to add new measurement options for Warfarin [# Out of INR (as defined by the facility)]/[# of INR Readings] and Insulin [# BELOW range (as defined by the facility) Blood Glucose Readings]/[# of Blood Glucose Readings] that will make the data extraction faster and more accurate. With this new measurement option, we expect that the submissions that we receive by April 25 (for the May monthly report) will show a dramatic participation rate improvement. 6

ADVERSE DRUG EVENTS (ADE) Incorporate Medication Affinity Group toolkits and recommendations into the meeting topics (May 2013 ADE Advisory Committee topic will be anticoagulant safety.) Provided hospitals with link and instructions to remove all recalled B-D Vacutainers that could be causing inaccurate aptt readings and subsequent dosing adjustment errors included link and explanation in our April 1 Newsletter. Ensure that data related to present on admission is screened out of the data reporting Confirmed our methodology with the Nevada Rural Hospital Partners regarding the ADE data collection methods and metrics so that we can begin to receive data. o Rural and CAH hospitals will be reporting different metrics on ADE into a central point so that the HEN receives the data from one point person who will collect and report on their behalf. Their metrics will include the number of sentinel event ADEs reported (this is submitted on an annual basis we will receive through 12/12). Also, we are working with them to correlate their Pediatric Weight process monitor as it related to ADEs in this same population (pediatric weight-based dosing ADE).These monitors will be tracked and reported separately. During our Taking Stock site visits, we validate that our facilities have up-to-date INR protocols, Blood-glucose protocols, have adjusted their Hydromorphone dosing parameters, and the availability and proper use of Smart-pumps (built in lockout thresholds by service line and age/weight) and PCA (patient-controlled analgesia) pumps and validating that all the recalled Vacutainers are truly removed from stock. As deficiencies are discovered, we work 1:1 with them to provide technical assistance. HOSPITAL STRATEGIES TO MOVE TOWARDS A 40% REDUCTION: Continue creation of evidence-based protocols and order sets. Team Rounding and Interdisciplinary Plan of Care documentation to coordinate and communicate with other team members Hand-off communication & Electronic Medical Records (EMR) documentation enhancements True dosing double checks of syringes and pumps use of Smart Pumps Validate Point of Care test results prior to dosing incorporate into EMR processes Reducing insulin product varieties in stock Move toward unit of use and away from multi-dose vials, when possible. Evaluate possibility that the lab tubes used for blood collection could be contributing to (falsely) increased aptt values. 7

CATHETER ACQUIRED URINARY TRACT INFECTIONS (CAUTI) Catheter Acquired Urinary Tract Infections Report Method: NHSN and Self-Report % of Hospitals Reporting: 71% (24/34) ANALYSIS OF THE SELF-REPORTED DATA SET: This cohort includes 13 unique facilities not included in the NHSN cohort above (12 of these reported data within the past 6 months). There was a large change in the aggregate trend for this group since last month s report which reflects a change in the hospital mix within this group. Our NHSN group is comprised of all Acute Care Hospitals (ACHs) and these facilities have been removed from our self-report group; therefore our self-report group is increasingly comprised of facilities (LTACs and Rehabs) with higher risk patients. Of the 12 facilities reporting during the current period 5 are LTACs and Rehabs, 2 of those LTACs reported data for the first time this month (which is great) however they only reported data in 2012 so they are not included in the benchmark and have rates higher than the HEN average because of their high risk patient population. 8

CATHETER ACQUIRED URINARY TRACT INFECTIONS (CAUTI) ANALYSIS OF NHSN DATA SET: NHSN data currently covers the time period from January 2011 to February 2013. The benchmark is the 2011 average and the current time period is the rolling 12 month average (March 2012 to February 2013). With more facilities signing Data Use Agreements, there are now 11 facilities represented in this cohort all ACHs. o o o o The CAUTI rate for this metrics is still showing a rate increase (27%), which is a 29% decrease as compared to last month. We are receiving data from the CMS QIO and Nevada Hospital Association (NHA) Comprehensive Unit-based Safety Program (CUSP) CAUTI project which has increased our reporting rate and reduced duplication of efforts and decreased the data burden for some of our facilities. Because 14 NV HEN Hospitals are participating in the QIO and CUSP CAUTI and will receive their technical assistance through that affiliation we are collaborating with them to reduce the CAUTI rate in Nevada. Beginning as early as 2011, the hospitals in the QIO and NHA CUSP CAUTI cohort have been receiving coaching on how to identify and properly report CAUTIs to ensure accuracy of their data. 9

CATHETER ACQUIRED URINARY TRACT INFECTIONS (CAUTI) o It is also interesting to note that the Catheter Utilization Rate for the NHSN cohort has decreased by 17%. Reducing the Catheter Utilization Rate is one of the goals of the QIO CAUTI program which is good for patients because less catheter days means less chance of developing a CAUTI. However, this could be another reason that our CAUTI rate could be going up since we are using catheter days as our denominator. SUCCESSES: NHSN cohort show decreases from their baselines for Catheter Utilization process measure. Our facilities reporting to NHSN show a 16% decrease between their 2011 average and their most current rolling 12-month average. Hospitals L, X, H, G, V, 2 and P are showing good results and are targeted as mentor hospitals for their associated sister chain facilities. All, but 2 of these facilities are enrolled in a CUSP collaborative. OPPORTUNITIES FOR IMPROVEMENT: Continue to obtain DUAs to improve number of hospitals reporting without creating additional burden on our facilites Work with facilities who report to NHSN data to obtain older benchmark Increase interventions and proper tool-kit use to improve the relative reduction to 40% HEN STRATEGIES TO MOVE TOWARDS A 40% REDUCTION AND INCREASE THE NUMBER OF HOSPITALS REPORTING DATA: Facilitate the high performing hospitals to share their best practices with other hospitals via monthly calls, success stories, meeting presentations, etc. Share information and tools from the NCD via newsletter, learning sessions, Health Community website and 1:1 coaching Include CAUTI as a topic for discussion and brainstorming on our May 2013 monthly HEN call. Share NV HEN Bright Spots strategies and those from other HENs with the group During Taking Stock visits, validate daily rounds for CAUTI surveillance. For those NV HEN facilities not engaged in the QIO or CUSP CAUTI effort and showing the need for improvement, we will provide 1:1 technical assistance that mirrors the CUSP methodology. CUSP methodology applies to all HACs and it is a common theme throughout our interventions. During our April Plenary, we have blocked time for a presentation to promote and understand CUSP methodology as an intervention strategy for reducing patient harm in the broader context of the HEN goals under the Partnership for Patients HOSPITAL STRATEGIES TO MOVE TOWARDS A 40% REDUCTION: Utilize the strategies developed by the NHA and QIO CUSP collaborative(s) of Unit-Based Safety Programs 10

CENTRAL LINE ACQUIRED BLOODSTREAM INFECTIONS (CLABSI) CLABSI Infection Reduction Report Method: Self-Reported and NHSN Data % of Hospitals Reporting: 70% (21/30) NHSN Data Self-Reported Data SUCCESSES: Self-Reported data is showing a 32% decrease from baseline 7 facilities have achieved level 3, 4 or 5 status OPPORTUNITIES FOR IMPROVEMENT: There was a large change in the aggregate trend for this group since last month s report which reflects a change in the hospital mix within this group. Our NHSN group is comprised of 11 ACHs and these facilities have been removed from our self-report group; therefore, our self-report group is increasingly comprised of facilities (LTACs and Rehabs) with higher risk patients. We will target these facilities for more aggressive technical support and also ensure that their data does not include present on admission stats. Collect data on ALL patient care areas, not just selected units move out of the initial CUSP CLABSI focus areas. 11

CENTRAL LINE ACQUIRED BLOODSTREAM INFECTIONS (CLABSI) HEN STRATEGIES TO MOVE TOWARDS A 40% REDUCTION AND INCREASE THE NUMBER OF HOSPITALS REPORTING DATA: During Taking Stock ensure that the CLABSI toolkits and interventions are applied to ALL settings, not just selected units. If not, set timelines and targets for the spread to all units. HOSPITAL STRATEGIES TO MOVE TOWARDS A 40% REDUCTION: Nevada State Health Division has offered the voluntary data collection of Hemodialysis Catheter infection data to NHSN (not officially required until 2014). We are encouraging our hospitals to embrace this opportunity to look at this population as early as possible so that problem discovery and intervention attempts can begin proactively - so far 3 hospitals have made this commitment and will begin data collection on April 1. 12

EARLY ELECTIVE DELIVERY Report Method: Self-Report % of Hospitals Reporting: 75% (9/12) 79% improvement from baseline Our most recent data shows a 79% decrease in early elective deliveries from the baseline of January 2010. Over 60% of the hospitals in the HEN that offer obstetrical services are reporting their data. SUCCESSES: The majority of the reporting hospitals have a hard stop policy (we are confirming the remainder). Many are partnering with physician champions at their facilities to help enforce the policies. Four of our hospitals have obtained a grant from the March of Dimes to work on problem. OPPORTUNITIES FOR IMPROVEMENT: Assist hospitals to improve patient engagement on this topic. Provide educational posters and pamphlets to the facilities and their major OB practice offices to help patients understand the risks and encourage them to make decisions based on the science of safety for their newborns. Continue to work with our facilities to obtain 2010 benchmark data. 13

EARLY ELECTIVE DELIVERY HEN STRATEGIES TO MOVE TOWARDS A 40% REDUCTION AND INCREASE THE NUMBER OF HOSPITALS REPORTING DATA: Our goal is to achieve a 90% decrease in Early Elective Deliveries by the end of the 3 rd quarter. Within the last month, we had another hospital with obstetrical services join our HEN. This hospital also has a hard stop policy and physician champions. We anticipate it will be instrumental in helping us reach this new goal. We are also working with the Strong Start campaign to prevent premature births and have asked our hospitals to share the campaign information with their patients. HOSPITAL STRATEGIES TO MOVE TOWARDS A 40% REDUCTION: Establish hard-stop policies in facilities that currently do not have one in place. Provide 2010 baseline data on EED to the HEN. Make Educational materials available to the patients. 14

OB ADVERSE EVENTS OB Adverse Events Report Method: CHIA % of Hospitals Reporting: 100% (12) SUCCESSES: The data through the 3rd quarter of 2012 shows that our hospitals have experienced an overall decrease in OB trauma events. For birth trauma with injury to neonates, the HEN has realized a 13% decrease from the baseline. OB trauma, vaginal delivery with instruments events have decreased by 14% from the baseline. Similarly, OB trauma, vaginal delivery without instrument events have declined 18% from the baseline. WHAT WORKED: Hospitals (Z & K) are using fetal monitoring simulation as part of their online obstetrical education. Hospital (V) has set Pitocin protocols in place to make inductions safer. HEN hospitals (K,N,U,Y) are running quarterly drills, so OB staff know how to handle emergencies like should dystocia and postpartum hemorrhage. 15

OPPORTUNITIES FOR IMPROVEMENT: OB ADVERSE EVENTS Even though the data is moving in the right direction, we continue to strive towards the 40% reduction goal. HEN STRATEGIES TO MOVE TOWARDS A 40% REDUCTION AND INCREASE THE NUMBER OF HOSPITALS REPORTING DATA: The NV HEN, in conjunction with the University of Nevada School of Medicine, has offered hospital staff Advanced Life Support Obstetrics and Care Team OB training. These two trainings provide simulations, roleplaying, and team building skills to help the OB staff deal with obstetrical emergencies like breech delivery, postpartum bleeding, and shoulder dystocia. All of these training techniques can assist in further reduction of all three categories of OB Adverse Events. We have a TeamSTEPPs (team training) scheduled for four of our OB hospitals this summer. This education will further previous efforts to improve communication among members of the OB staff at our hospitals. Team communication is the first step to meeting our 40% reduction goal. We have set a goal for an additional 10% decrease in OB adverse events by the end of the 3 rd quarter. HOSPITAL STRATEGIES TO MOVE TOWARDS A 40% REDUCTION: The hospitals are continuing to run drills for OB emergencies. Some of the hospitals have also participated in Advanced Life Support in Obstetrics training and Care Team OB training to improve their skills handling situations that result in these adverse events. The goal of this program is to first, train staff to establish spread within their primary facilities with a train the trainer approach. Subsequently, these trainers will be used to spread this knowledge to other facilities in Nevada. 16

FALLS WITH SIGNIFICANT INJURY Report Method: CHIA % of Hospitals Reporting: 91% (31/34) ANALYSIS OF CHIA DATA SET: The source for our Falls with Injury measure is the Center for Health Information Analysis (CHIA) database. All hospitals in Nevada are required to submit monthly billing data to CHIA, who then publishes the data on a quarterly basis with a 4-6 month data lag. Using this database allows us to use a validated data source to have a broader picture of almost all of our HENs while decreasing the data burden on our member facilities. Since falls are not coded in billing data, the NV HEN uses the CMS HAC definition to estimate the number of falls with injury. To clarify, we count the number of fractures, dislocation, intracranial injuries, crushing injuries, burns and other injuries that were not present on admission or that are not the primary or secondary diagnosis. Despite the fact that the CMS HAC data is a proxy measure for falls, we are encouraged that the rate of these traumatic injuries are decreasing and do see parallels between the CMS HAC CHIA data and the Bright Spot success stories and self-reported data supplied by some of our facilities. This decrease in the Falls with Injury rate demonstrates improved patient safety and reduced healthcare costs. SUCCESSES: Continued improvement as latest CHIA data shows a 39% decrease from a 2010 baseline. 18 facilities achieved level 3 status, 2 have achieved level 4 status. CHIA data shows Facility (Z) has demonstrated exceptional success with a 61% reduction in 2012 (9 month average) from a 2010 baseline and will be highlighted in a success story (see hospital strategies). 17

FALLS WITH SIGNIFICANT INJURY WHAT WORKED: Utilizing Patient Assessment Teams to determine patients at risk for falls (ALL) Making ALL staff responsible for falls prevention (2,6,A,R,S,Z,Y) Falls prevention signage and garments (A,R,S,Z,Y,U) Engaging patient and family in falls awareness and post falls huddles (2,6,A,S,Z) Utilizing root cause analysis following an incident (ALL) Utilizing Bed Alarms and assistive devices (ALL) Indicating lift/transfer requirements on white boards and or signage (ALL) Scheduled toileting for at-risk patients (A,R,S,Z) OPPORTUNITIES FOR IMPROVEMENT: Five facilities (M,R,V,T,Y) have identified the need for more technical assistance. Promote the Touro Falls Program as an on-site training opportunity at no cost to the facility. HEN STRATEGIES TO MOVE TOWARDS A 40% REDUCTION AND INCREASE THE NUMBER OF HOSPITALS REPORTING DATA: We will partner the mentor hospitals with the others to share best practices We will provide additional 1:1 assistance as needed to facilitate RCA for all falls with serious injury to identify and mitigate future high-harm events Touro Falls program will be presented at April Plenary. Sharing information from Pacing Events, national toolkits and success stories (the monthly calls, monthly newsletter, and educational sessions). We will focus on this HAC during an upcoming Monthly HEN Call. We have identified a potential speaker from AHRQ, and also invited Touro University to participate and will pre-select some of our HEN facilities to share their successes and challenges. HOSPITAL STRATEGIES TO MOVE TOWARDS A 40% REDUCTION: Mentor hospitals will share strategies for improvement with other hospitals Utilize root cause analysis for fall events. (RCA training will be offered in May 2013.) Patient-Family Engagement strategies geared to partner in prevention During a site visit to Facility (Z), the team witnessed the interventions put in place to reduce falls including patient sitters, yellow magnets on the doors of high risk patients, and colored garments on high-risk patients and lift/transfer requirements noted in patient room. One facility (Y) is interested in discussing Touro Falls Program further. 18

PRESSURE ULCERS Pressure Ulcers Report Method: CHIA % of Hospitals Reporting: 91% (31/34) SUCCESSES: 21 facilities have achieved level 3, 4 or 5 status. Facility (1) has had a 70% reduction in 2012 (9 month average) from a 2010 baseline. (See What Worked for details.) WHAT WORKED: Utilizing Patient Assessment Teams to determine patients with high risk for pressure ulcers Making ALL staff responsible for pressure ulcer prevention, implementation of increased skin assessment on hourly rounding. Use of Med-Line Pressure Ulcer measurement tool (or other similar assessment tool) (Y,U,T,N,Z,K) Facilities (A,S,Z,2,6) provide patient engagement education in verbal and written forms to engage patients and family in pressure ulcer awareness. Utilizing root cause analysis following an incident (All) (RCA training offered May 2013.) Products Review Committees identify prevention options and pilot new techniques (All) Specialty beds, Moisture Barriers, Pressure Point buffers, Proper Nutrition (J,K,L,M,N,R,Q,A,Z,Y,2,6,7,8) Increased awareness with development of Pressure Ulcer Advisory Committee started March 2013. 19

PRESSURE ULCERS Facility (1) has enhanced their wound care program through officially forming a Wound Care Task Force in December 2010, due to the patient type they were admitting with multiple complex wounds. This allowed for improved intervention and monitoring. The team is comprised of 3 full-time wound care specialists (a Wound Care Coordinator and 2- Wound Care Nurses) who all are wound certified. Interventions applied by the team include the use of the Braden Scale, Bates-Jensen Wound Status Tool (BWATs), International Pressure Ulcer Prevalence (IPUP) Survey and CMS mandatory wound care assessment. The Wound Care Team have also participated in the Ulta Vac Trial done by Hill-rom (Negative Pressure Wound Therapy) and have seen remarkable results. The team also contributes their success to increased collaboration with the other clinical disciplines and physicians. OPPORTUNITIES FOR IMPROVEMENT: Increase awareness of best practice in wound preventions and care through Advisory committees and educational seminars, this topic will continue to be prioritized by the HEN to move toward the 40% improvement goal. LTAC and REHAB Facilities are showing the most increase (61%) from baseline and will require a high level of HEN support and intervention Having more facilities at level 3 status HEN STRATEGIES TO MOVE TOWARDS A 40% REDUCTION AND INCREASE THE NUMBER OF HOSPITALS REPORTING DATA: Pressure Ulcer Advisory Team (Wound Nurses, Nutritionists, Physical Therapists) to hold second meeting in May. Share best practices and toolkits that they will bring back to their facilities for implementation Invite all HEN facilities front line wound care clinicians to seminar presented by nationally recognized expert on pressure ulcers (Dr. Joyce Black) May 2013. We will partner the mentor hospitals with the others to share best practices We will provide additional 1:1 assistance as needed to facilitate RCA for Stage III, IV Pressure Ulcers to identify and mitigate future high-harm events Sharing information from Pacing Events, toolkits and success stories via newsletter, monthly call and education sessions. Education of front line wound care clinicians as to Best Practice technique for identifying and document wounds in hard chart and EMR. This improves care through proper identification of level of care needed to prevent or promote healing to wounds. HOSPITAL STRATEGIES TO MOVE TOWARDS A 40% REDUCTION: Mentor hospitals will share strategies for improvement with other hospitals Implement new tools and activities to assess and prevent pressure ulcers Utilize root cause analysis for events Patient-Family Engagement strategies geared to partner in prevention Implementation of improved documentation in EMR for prevention of miscoding 20

SURGICAL SITE INFECTIONS (SSI) % of Hospitals Reporting: 74% (14/19) Self-Reported Data NHSN Data SUCCESS: Although our data shows a 1.3% increase in SSIs from Hysterectomies from baseline (Q1 2012), our NV HEN facilities are actually doing quite well in this measure. The baseline of Q1 of 2012 only has 2 SSIs, therefore, it will be difficult for us to ever show improvement in this category. The measure comes from NHSN and is comprised of 8 hospitals and we have access to the data from January 2012 through January 2013. An Australian study on the AHRQ website estimates that between 2% and 13% of patients experience an SSI following a hysterectomy 1. Given this information, we would expect our 8 HEN facilities to have had 22 to 146 hysterectomies during 2012 given the 1,128 hysterectomy procedures that were performed. These 8 facilities collectively only reported 10 SSIs, therefore it seems that the NV HEN facilities reporting data to NHSN are doing quite well. 1 Australian Council on Healthcare Standards (ACHS). ACHS clinical indicator users' manual 2012. ULTIMO NSW: Australian Council on Healthcare Standards (ACHS); 2012 Jan. various p. 21

SURGICAL SITE INFECTIONS (SSI) NHSN COLO SSI RATE 11 facilities, 35% decrease from baseline Total facilities represented = 14 (total 20 eligible, 74%) 6 facilities achieved level 3 or 4 status. Self-Report - [All SSI]/[All Surgeries], 9 facilities (not submitting data to NHSN), 28% decrease from baseline (2010 Avg. vs. 2012 Avg.) 2 Facilities committed to SUSP Cohort 2 (Q & 9) OPPORTUNITIES FOR IMPROVEMENT: Obtain more historical data from the facilities reporting data into NHSN. Enroll more hospitals in future SUSP Cohorts. HEN STRATEGIES TO MOVE TOWARDS A 40% REDUCTION AND INCREASE THE NUMBER OF HOSPITALS REPORTING DATA: Share best practices and toolkits that they will bring back to their facilities for implementation We will partner the mentor hospitals with the others to share best practices We will provide additional 1:1 assistance as needed to facilitate RCA for SSI events to identify causes and solutions to mitigate future high-harm events training events scheduled for May 2013. Sharing information from Pacing Events, toolkits and success stories via newsletter, monthly call and education sessions. Partner with the Nevada Division of Health to conduct training before July 1, 2013, on infection prevention. HOSPITAL STRATEGIES TO MOVE TOWARDS A 40% REDUCTION: The HEN is sponsoring 2 hospitals in the SUSP project (Cohort 2) who have completed their HSOPS survey. They are currently engaged in team building and training and NHSN data upload to SUSP. Project JOINTS (IHI) was presented at our March 28 monthly HEN call the SSI prevention best practices will apply to ALL types of surgery (not just knees and hips). Links to the toolkit were provided. o One hospital (Z) described their year journey through rapid process cycle SSI process improvement that has resulted in getting all physicians to agree to multi-application chlorhexedine preps; reduction of flash sterilization and buy in of physician and staff champions to move the initiative forward. Our Antibiotic Stewardship/HAI Steering Committee met on March 21, 2013 and agreed on a strategy to engage more stakeholders within the state (e.g. Infection Control Preventionist for the VA System; State Epidemiologist) to help focus infection control efforts that will affect SSI and other HACs. Performing a cost and task proposal to justify a Regional Prevalence study on virulent agents 22

VENTILATOR ASSOCIATED PNEUMONIA (VAP) Ventilator Associated Pneumonia Report Method (VAP/VAE): SUCCESS: CHIA % of Hospitals Reporting: 79% (23/29) 79% data participation 12 facilities achieved level 3 or 4 status. 45% decrease from baseline WHAT WORKED: Use of toolkits and bundles Utilizing root cause analysis following a true VAE incident (RCA training May 2013). OPPORTUNITIES FOR IMPROVEMENT: Emphasize sedation vacations, ambulation and other strategies to allow more effective ventilator care Continue assessment of facilities for implementation and understanding of new NHSN criteria for VAE HEN STRATEGIES TO MOVE TOWARDS A 40% REDUCTION AND INCREASE THE NUMBER OF HOSPITALS REPORTING DATA: Share best practices and toolkits that they will bring back to their facilities for implementation We will partner the mentor hospitals with the others to share best practices We will provide additional 1:1 assistance as needed to facilitate RCA for VAE events to identify causes and solutions to mitigate future high-harm events Sharing information from Pacing Event, toolkits and success stories, via newsletter, monthly call and educational sessions During Taking Stock validate that they understand and can input data to NHSN for VAE. Our Respiratory Advisory Committee has agreed to network and assist each other during this conversion period so we will pair hospitals to learn from each other. Once the VAE data posts from NHSN, we will analyze it as compared to the previous VAP data HOSPITAL STRATEGIES TO MOVE TOWARDS A 40% REDUCTION: Mentor hospitals will share strategies for improvement with other hospitals Implement new tools and activities to prevent VAP Respiratory Advisory Committee cross-walked new VAE data collection for NHSN reporting to ensure accurate and useful hospital-specific trending data 23

VENOUS THROMBOTIC EVENTS (VTE) Venous Thromboembolism Report Method: CHIA % of Hospitals Reporting: 91% (31/34) SUCCESS: 91% data participation 12 facilities achieved level 3, 4 or 5 status 15% decrease from baseline past 2 months: 11% decrease in January report, and 15% decrease in February report WHAT WORKED: Use of toolkits and bundles Proper anticoagulation assessment that balance risk/benefit for patient Multi-pronged interventions: pharmaceutical and non-pharmaceutical AHRQ VTE Tool-Kit shared with membership Utilizing root cause analysis following an incident (RCA training May 2013.) Treatment pathway guided by patient risk assessment OPPORTUNITIES FOR IMPROVEMENT: Having more facilities at level 3 status During Taking Stock do an assessment of facilities for implementation of strategies to all patients, not just surgical 24

VENOUS THROMBOTIC EVENTS (VTE) HEN STRATEGIES TO MOVE TOWARDS A 40% REDUCTION AND INCREASE THE NUMBER OF HOSPITALS REPORTING DATA: We will partner the mentor hospitals with the others to share best practices We will provide additional 1:1 assistance as needed to facilitate RCA for VTE events to identify causes and solutions to mitigate future high-harm events (workshops will be held in May 2013) Sharing information from Pacing Events HOSPITAL STRATEGIES TO MOVE TOWARDS A 40% REDUCTION: Mentor hospitals will share strategies for improvement with other hospitals Implement new tools and activities to prevent VAP Progress toward increased use of mechanical interventions Utilize root cause analysis for events 25

FORWARD LOOK FOR NEXT 30 DAYS: Continue 1:1 meetings to stimulate data flow, provide tools and best-practice in areas of challenge. Continue monthly teleconference for participants run like office hours focus on providing education, speakers, tools and technical assistance to assist in attaining the goals (April topic of focus AHRQ toolkit implementation Falls and VTE) Provide an initial draft of a data dashboard to send out to our hospitals to allow them to view their data against HEN aggregate performance and internal, individual monitoring we project this draft to be available in May 2013 for input and revision by the target audience Continue Weekly NV HEN Newsletter and expand distribution list to reach as many people as we can to spread the good news of what the HEN is accomplishing and helpful links to best-practices and national PfP news. Provide RCA training sessions (6 hours, projected for May 2013) to help them understand the basic process and follow-up to be truly effective in action plans and also the value and concept on including patients in this process Continue to obtain Data Use Agreements for relevant facilities Obtain the newest (4 th Quarter 2012) data from the Center of Health Information Analysis center Identify national cost savings formulas and patient lives impact, per HAC Coordinating the next learning sessions of the UNSOM-NV HEN sub-contract to provide TeamSTEPPS training in Advanced Life Support for Obstetrics (ALSO) and Team Care OB. Interface with the new CMS Innovation project Strong Start as an extension of our HEN initiative to address OB Adverse Events. Obtain and distribute March of Dimes educational materials for patients in our OB services and their affiliate physician offices Leslie Smith (NV HEN Project Coordinator) will be working with Hospital N to provide advisory assistance on the development of their new Patient Engagement Committee process. She will help them kick-start their meeting agendas, goals and organization for this project and provide discussion facilitation at their initial meetings. Continue SUSP program (Phase II) and associated NHSN data entry Plenary Learning Session (Spring 2013) - these sessions are open to ALL participants, not just NV HEN members. Procure nationally recognized keynote speakers on topics of need. Goal of Plenary is to facilitate cross-learning and sharing between facilities Gain more knowledge regarding the Meeting Approval process through CMMI and HHS. ANY COLLABORATION WITH OTHER ORGANIZATIONS LIKE BUT NOT LIMITED TO QIO, STATE HEALTH DEPARTMENTS, COMMUNITY CARE TRANSITIONS PROGRAMS AND OTHER HENS: Northern Nevada Infection Control Committee NHA Hospital Patient Safety Committee Adverse Medication Events (Community) Health Information Exchange Transitional Care Nevada Division of Health (NV HAI) Nevada Hospital Association NV QIO Nevada Rural Hospital Partners Rural Hospital Affinity Group SpeakerLink Empowered Patient Coalition 26

FORWARD LOOK FOR NEXT 30 DAYS: HONOReform NV AARP Nevada Geriatric Education Consortium Touro University evidence-based Falls program Univerity of Nevada School of Medicine (Obstetrics) TeamSTEPPS training, ALSO program Team Care OB Roseman College of Pharmacy and Nursing Professional Societies and Boards Greater New York Hospital Association (HAI success) CDC Get Smart for HealthCare Campaign Safe Maternity Care Coalition Nevada Partnership for Value-Driven Healthcare Nevada Geriatric Education Consortium PSPC Version 5.0 (through NHA) Medication Safety Affinity Group (MSAG) member NV Association of Healthcare-System Pharmacists University of Nevada Center for Health Information Analysis (CHIA) POLST (Palliative Care) Initiative Strong Start Grant Team Governor s Office of Consumer Health Assistance Office of Minority Health Patient and Family Advisors and Leaders Network Nevada Action Coalition HEN Rural Affinity Group Project ECHO NV focused on Rural and CAH education LiCON (Liability Cooperative of Nevada) Vidant Patient Engagement Program NAPH HEN Leadership Engagement Southern Nevada Health District Nevada State Epidemiologists FINANCIALS (PER COR REQUEST): TOTAL AWARDED (BASE PERIOD): $2,162,676 EXPENSES: MARCH 1-31, 2013: $113,824 BALANCE-TO-DATE: $1,023,600 ATTACHMENTS - COMPLETE HOSPITAL LIST (WITH NAME AND LOCATION), THAT SIGNIFIES: 1. Any changes from previous month 2. Participation Table (new format) 3. Data display tables and aggregate graphs for Outcome and Process measures 4. HEN Aggregate dashboard template 5. HEN Interventions Grid by HAC 6. Success stories 27