Cohort 1A-C Coaching Call October 1, 2014 Facilitators: Lisa Carhuff Kathy McGowan Joyce Reid

Cohort 1A-C Coaching Call

October 1, 2014

Facilitators:

Lisa Carhuff

Kathy McGowan

Joyce Reid

Learn. Act. Improve. Spread. Keep the Drum Beat Going.2

WELCOME and Introductions

What is not started today cannot be finished tomorrow


2014 OAT Survey Announcement

• Planned distribution today!• Comparative survey – No changes in questions from the 2013!• Suggested list for gathering input will be included for each

domain• Due by October 24th


NOVI reporting of C. difficile

• Begin surveillance/collection of data October 1• Place October data into GHA Manual Data Entry by November

15th

• Contact Jan Ratterree with any questions related to data collection surveillance and/or reporting into NOVI– (770)-240-4518– [email protected]

4


What is required in Manual Data Entry to obtain accurate data:

• Numerator:– The number of C. difficile positive specimens in patients with specimen

collection day beginning with > 3 days after admission to the facility (i.e., on or after day 4).

• Important Numerator Definitions:– A + test for C. difficile is defined as:

• A positive laboratory test result for C. difficile toxin A and/or B, OR,

• A toxin-producing C. difficile organism detected by culture or other laboratory means performed on a stool sample.

– Do not report a Duplicate toxin-positive laboratory • (+) C. difficile toxin test result with prior (+) in ≤ 2 weeks in same patient

and same location

5


What is required in NOVI to obtain accurate data:

• Denominator:– Total number of Patient Days (do not count NICU and Well Baby)

– A daily count of the number of patients in the facility inpatient units during a time period. To calculate patient days, for each day of the month, at the same time each day, record the number of patients. At the end of the month, sum the daily counts and enter the total.

– If patient days are available from electronic databases, these sources may be used as long as the counts are not substantially different (+/_5%) from manually-collected counts

6


What is required in NOVI to obtain accurate data:

• Denominator:– We are following inpatients

• A patient whose date of admission to the facility and the date of discharge are different calendar days.

• Note: A patient who is admitted to an inpatient location as an “observation” patient is identified as an inpatient on the first and subsequent days for the purposes of surveillance.

7


“Reversing the Flatline” Readmissions Survey Results

Cohort 1 N = 41

• RCA in past 3 months = 7 Reason for readmissions

Transportation & Mental Health Issues

Patient education

Community Partners

Follow up Phone calls

Physician

Staff Education

CHC

Case Management Involvement

None

Leadership

Risk Assessment

Bedside Medication Delivery

Using data to drive

0 1 2 3 4 5 6 7

Cohort 1Promising intervention


Readmissions Data

2010 (Base-line)

11Q1 11Q2 11Q3 11Q4 12Q1 12Q2 12Q3 12Q4 13Q1 13Q2 13Q3 13Q4 14Q1 2010 (Base-line)

11Q1 11Q2 11Q3 11Q4 12Q1 12Q2 12Q3 12Q4 13Q1 13Q2 13Q3 13Q4 14Q1

# of Hosps

111 110 110 110 111 110 110 110 111 111 111 110 109 110

# Meeting HEN Target

18 26 30 26 22 33 33 34 36 36 42 44 44 47

# Meeting Nat'l Target

17 21 27 24 20 32 31 32 34 32 39 38 43 46

Readmission Rate

0.187745278723358

0.185314393148109

0.183164408407127

0.185463164131938

0.186109516703019

0.182037723279344

0.178928645676931

0.176299510663835

0.177206879950983

0.174094588836813

0.173520809898763

0.173147451570434

0.175056689342404

0.171239730968838

GA HEN Target

0.1524 0.1524 0.1524 0.1524 0.1524 0.1524 0.1524 0.1524 0.1524 0.1524 0.1524 0.1524 0.1524 0.1524

National Target

0.1496 0.1496 0.1496 0.1496 0.1496 0.1496 0.1496 0.1496 0.1496 0.1496 0.1496 0.1496 0.1496 0.1496

1.0%

3.0%

5.0%

7.0%

9.0%

11.0%

13.0%

15.0%

17.0%

19.0%

10

30

50

70

90

110

30 Day Readmission Rate- Medicare Only


HAC – NOVI data entry










“It’s a wonderful life” and the HEN Project

• Consider the past 3 years without the HEN– What has made the difference

for your hospital– Tell the “HEN story” for your

hospital


Cohort 1 – Safety Across the Board

• Share additional successes on any HEN Topic

• Best Practice Implementation questions?

• Any questions/comments regarding measures?

Learn. Act. Improve. Spread. Keep the Drum Beat Going.

Upcoming Events

• Next Cohort Coaching Call: Not Scheduled• HEN Celebration Webinar tentatively scheduled for November 19

Data Submission – August Data Due October 15: ADE’s including INR, BG, and Opioids Falls with injury VTE-6 (due once a quarter) HAI (if not submitting via NHSN) include CDI EED if applicable


EVALUATION

Remember Complete the evaluation for today’s Cohort 1 Coaching Call!

Documents

Cohort 1A-C Coaching Call October 1, 2014 Facilitators: Lisa Carhuff Kathy McGowan Joyce Reid