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Welcome to the Kentucky Hospital Improvement
Innovation Network - January Update
Agenda 1. Needs Assessments – due ASAP – no later than
1/30/17 2. Site Visits Update – potential weather issues 3. Fellowships – QI and PFE 4. 1-2-3 for Equity Pledge 5. SNAP – Safety Network to Accelerate
Performance 6. Data and Ky. Quality Counts Update 7. Topic-Based Info-Nuggets, Hospital Highlight,
and Upcoming HRET Events 8. Timeline and Next Steps
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Needs Assessment HRET Deadline 1/31/17 – As of 1/25 - 83% completed – thank you! Can be found on www.k-hen.com, on Data
page under “Tools” Complete and scan to [email protected] or fax to (502) 814-0355
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Site Visits
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The K-HIIN team is on the road again! So far - 20 Visits completed, thank you! If it looks like inclement weather may impact travel, we will contact you directly to discuss. Sign up on Signup Genius - http://www.signupgenius.com/go/10c0945afa923a13-khiin •All times are in Eastern Time Zone just to make it less confusing •If you don’t see a good date/time for your hospital, contact us directly - [email protected] or [email protected] Preparation – •Complete Needs Assessment •Invite key team members – Senior Leadership, clinical leaders, data collectors and analysts, physician leaders, risk managers, IP, etc. •Let us know location of meeting, media and Internet capabilities •Be thinking about your WHY and your areas of focus
Fellowships Back by popular demand!
1. QI Fellowships – KY enrollment: Foundations for Change – 13 enrollees Accelerating Improvement – 4 enrollees
2. Patient and Family Engagement – 6 enrollees Thank you for participating - there’s still time to sign up
for both – remember, our goal is to have at least one Fellow from each hospital!
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Disparities impact statement
#123forEquity
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#123ForEquity
#123forEquity Pledge National Call to Action Pledge to address the following areas in the next 12 months-
By end of month one, choose a quality measure to stratify by race, ethnicity, or language preference (or other socio-demographic variable such as income, veteran status, sexual orientation or gender, or other)
By end of month three, determine if a health care disparity exists in this measure – if yes, design a plan to address the gap
By end of month six, provide cultural competency training for all staff or develop a plan to ensure your staff receives cult. comp. training
By end of month nine, have a dialogue with board and leadership team on how you reflect the community you serve, and what actions can be taken to address any gaps if the board and leadership do not reflect the community you serve
Disparities impact statement
To promote the #123forEquity pledge, the IFD and the Disparities Solutions Center (DSC) at Massachusetts General Hospital are partnering to provide practical, actionable strategies to help HIIN hospitals meet the goals of the pledge by conducting regional “Improving Quality and Achieving Equity” trainings hosted by HIIN state hospital associations on a quarterly basis.
– The curriculum focuses on how to execute on each component of the pledge; leaders will then take these concrete strategies back to their hospitals to facilitate their successful execution, thus contributing to improving quality and diversity, eliminating disparities and achieving equity.
– Subject matter experts will help the participants develop a blueprint for action that they can share and present to their organizations as a guide along with the #123ForEquity Toolkit.
More information to come!
Oh SNAP!
• What is SNAP? Safety Network to Accelerate Performance • The first SNAP topic is enhanced recovery
after surgery with a focus on colorectal surgery.
• The SNAP page and application are now on the HRET HIIN website. Hospitals that are interested in participating in this SNAP should register for the informational call on February 2 at 2:00 p.m. CT. The registration link is available on the 'SNAP' and 'Upcoming Events' pages of the website. 10
DATA UPDATE
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Baseline Periods
Preferred Baseline Periods • Calendar year 2014 except:
– SIRs – Calendar year 2015 – to be collected after the NHSN rebaseline is completed in Dec 2016
– CAUTI & CLABSI – Calendar year 2015
Alternate Baseline Periods • Oldest 12, 9, 6, or 3 month consecutive period prior to
Oct 2016 • All Baseline Data Due to KHIIN – January 27, 2017
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Baseline Periods
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Data Submission
• MONTHLY – Beginning Oct 2016 – Site collected data will be entered into the KQC system by the
hospital – Site collected measures specific to your hospital will show up
on your KQC data entry page
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KY Quality Counts Data Collection System
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https://khaqualitydata.org
New Measures to HIIN
• Readmissions – Readmission Hospital Wide – Medicare Only
• Culture of Safety – Worker Safety – Harm events related to patient handling – Harm events related to workplace violence
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Readmissions Hospital Wide/Medicare
• Measure is a subset of the All Payor measure
• Specifications are the same except it applies only to Medicare patients
• Collect your data for All Payors first, then filter on only Medicare patients
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Culture of Safety - Worker Safety
• Harm events related to patient handling – Numerator – Number of worker harm events related
to patient handling for the time period – Denominator – Number of full-time equivalents (FTEs)
for the time period
• Harm events related to workplace violence – Numerator – Number of worker harm events related
to workplace violence for the time period – Denominator – Number of full-time equivalents (FTEs)
for the time period
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Worker Safety Data Sources
• Numerators – obtain from the OSHA 300 log – Recordable injuries include
• Death • Loss of consciousness • Days away from work • Restricted work activity or job transfer or • Medical treatment beyond first aid
• Denominator – obtain from Human Resources
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OSHA 300 Log
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Data Sources
Core Topic Site NHSN AHRQ ADE CAUTI CLABSI C. diff Falls Pressure Ulcer (Prevalence) (Rate) Readmissions Sepsis SSI VTE VAE
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Data Sources
Additional Topics Site NHSN AHRQ
MRSA Culture of Safety – Worker Safety*
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*Worker Safety measures are already collected on the OSHA Log
And a Few Info-Nuggets
Adverse Drug Events
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Antibiotic Stewardship Program
• Checklist for Core Elements of Hospital Antibiotic Stewardship Program: – Leadership Support – Accountability – Drug Expertise – Actions to Support Optimal Antibiotic Use – Tracking: Monitoring Antibiotic Prescribing, Use
and Resistance – Reporting Information to Staff on Improving
Antibiotic Use and Resistance – Education
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Pharmacy Champions
• Looking for Pharmacy Champions!!! • Complete your Pharmacy Survey today https://www.surveymonkey.com/r/K-HIINPharmacy
It is not too LATE….54 have been received
as of Monday, January 23 – I’m missing yours!!!
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And a Few Info-Nuggets
Readmission Views From the Road • Readmissions are expensive • Readmission are a significant part of Quality
Improvement • Many tools are being used including
– LACE, RED, Special Projects, Data Analysis
• Hospitals are routinely involved in their communities to reduce readmission - outside the walls. • Significant challenges exist with chronic conditions or
CHF, COPD, Diabetes, Aging
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Hospital Highlight – Taylor Regional
Engaging your Environmental Services Department in Infection Prevention –
Shannon Davis, RN – IP at Taylor Regional Environmental Services Certification Course in
Collaboration with Campbellsville University
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Upcoming HRET Events
HRET HIIN CLABSI Virtual Event – January 26 from 12:00 p.m. – 12:50 p.m. ET
HRET HIIN QI Fellowship Foundations for Change Virtual Event #2 – February 1 from 12:00 – 1:00 p.m. ET
HRET HIIN QI Fellowship Accelerating Improvement Virtual Event #2 – February 1 from 1:30 – 2:30 p.m. ET
HRET HIIN VTE Virtual Event – February 7
http://www.hret-hiin.org
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Upcoming HRET Events
• I Screen, You Screen, Let’s All Screen for Sepsis! – February 9
• Adjuncts and Alternatives to Opioids for Pain: It’s All About Love – February 14
http://www.hret-hiin.org
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Timeline and Next Steps • Needs Assessments – complete and send
if not done already • Site Visits - Schedule yours now if not
already scheduled • Join the Fellowship! • Continue entering Monitoring Data into
KQC >
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KEEP CALM AND HIIN ON
Questions?
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