GEORGIA H

OSPITA

L ENGAGEMENT

NETWORK

COHORT C

OACHING C

ALL

JUNE 1

8, 2014

CO

HO

RT

2 +

CO

HO

RT

3 +

CO

HO

RT

4 =

CO

HO

RT

“ 9”

FRAMING

• Status Report HEN Measure by Measures • Reviewing data, • Sharing successes and barriers• Offers and Request

• Disparities• Spread

• C. diff prevention• Sepsis prevention• Worker’s Safety

• Calendar Review

DA

TA S

NA

PS

HO

T

Measure Most Recent Period

Number of hospitals reporting

this measure

Target rate

Number of hospitals meeting

benchmark/ goal for this

measure

Number of hospitals

reporting “0” for most recent

reporting period for this measure

Current adverse event

rate for this measure

Number of hospitals reporting that they have a prevention bundle in place for

this AEA (BPSS) based on Q2-2014 BPSS

Anticoagulant Control ADE March 2014 95 2% 70 42 0.91% 85 of 87

Glycemic March 2014 97 0.60% 66 33 0.50% 82 of 87

Opioid ADE March 2014 80 Not Available n/a 39 1.95/1000 74 of 87

Falls with Injury March 2014 96 0.50 65 52 0.43/1000 84 of 87

EED March 2014 52 2% 46 46 1.49% 35/42

PrU Q1 2014 109 0.33 87 87 0.62 71 of 87

PE/DVT Q1 2014 109 4.05 63 53 5.09 77/87

Injury to Neonate PSI17 Q1 2014 60 1.208 39 39 2.18 34/42

OB AE with Inst-PSI18 Q1 2014 57 84.86 22 16 125.85 34/42

OB AE w/o Inst- PSI19 Q1 2014 62 13.7 19 14 22.94 34/42

CAUTI March 2014 84 0.48 62 62 2.29 85/87

CLABSI March 2014 82 0.48 69 69 0.79 74/79

SSI:Colon March 2014 39 1.7 34 34 3.05 44/73

SSI:Hyst March 2014 32 0.9 30 30 0.81 44/73

Readmission All Payer Q1 2014 111 9.24% 31 1 11.48% 67/87

Readmission Medicare January 214 110 15.24% 43 7 17.07% 67/87

FALL

S W

ITH

INJU

RY

FALLS AND TRAUMA

HOSPITAL ACQUIRED PRESSURE ULCERSSTAGE III-IV

HOSPITAL ACQUIRED PRESSURE ULCERS

STAGE II ONLY

PO

ST

OP

PE

/DV

T (

PS

I-12

)

AD

E –

GLY

CE

MIC

CO

NT

RO

L

OPIOID RELATED ADVERSE EVENTS

Current Rate/1000

4.0 15

reporting

Alternative Numerator #1: Number of orders for sedation or opioid reversal administration per month outside of the operating rooms, procedure rooms or ED for all adult inpatients >18 y.o. Alternative Denominator #1: Total number of narcotics (opioids) orders outside of the operating rooms, procedure rooms or ED for all adult inpatients >18 y.o.

1.60 41

reporting

Alternative Numerator #2: Number of opioid reversal doses administration per month outside of the operating rooms, procedure rooms or ED for all adult inpatients >18 y.o. Alternative Denominator #2: Total number of narcotics (opioids) doses administered outside of the operating rooms, procedure rooms or ED for all adult inpatients >18 y.o.

12.2 24

reporting

Alternative Numerator #3: Number of opioid reversal doses administration per month outside of the operating rooms, procedure rooms or ED for all adult inpatients >18 y.o. on “PCA Pumps” (pain control pump). Alternative Denominator #3: Total number of adult inpatients >18 y.o. placed on a pain(PCA) pump with narcotics (opioids) doses administered outside of the operating rooms, procedure rooms or ED

1.95 80

reporting

Overall rate based on the number of opioid related adverse events per 1000 X the total exposures to potential opioid related events.

AD

E-

AN

TIC

OA

GU

LAN

T C

ON

TR

OL

VA

SC

ULA

R C

AT

HE

TE

R

AS

SO

CIA

TE

D IN

FE

CT

ION

(C

MS

-H

AC

7)

CLA

BS

I -N

HS

N

CA

TH

ET

ER

AS

SO

CIA

TE

D

UT

I (C

MS

HA

C6

RE

V)

CAUTI CMS--HAC6

CA

UT

I-N

HS

N

EA

RLY

ELE

CT

IVE

DE

LIV

ER

Y

RA

TE

OB

AD

VE

RS

E E

VE

NT

S

OB

AD

VE

RS

E E

VE

NT

S

OB

AD

VE

RS

E E

VE

NT

S

RE

AD

MIS

SIO

NS

DISPARITIES

CDC -- ACTION TO REDUCE DISPARITIES

Conclusion and Future Directions: CDC Health Disparities and Inequalities Report — United States, 2013

• http://www.cdc.gov/mmwr/preview/mmwrhtml/su6203a32.htm?s_cid=su6203a32_w

DISPARITIES BOLD AIM

The Census Bureau predicts that racial and ethnic minority populations in the U.S. will grow to become half of the U.S. population in three decades.

Georgia’s Hospital Engagement Network wants to work with hospitals

across the state to address the increasing health needs of racial and ethnic

minorities, rural and urban poor, and other medically underserved

populations in the midst of efforts to strengthen the healthcare system and

improve access to care for millions of Americans.  Eliminating health

disparities is a priority for GHA and involving diverse communities and

partners will be critical in its effort directed at achieving health equity in

America.

GEORGIA ADVANCED PRACTICE PROJECT

Spreading Best Practices for:

• C. diff Prevention and Sepsis Resources https://

quality.gha.org/Home/HospitalEngagementNetwork/LEAPTGAPP/Resources.aspx

• Worker’s Safety https

://quality.gha.org/Home/HospitalEngagementNetwork/LEAPTGAPP/WorkerSafety.aspx

GHA’S WORKER SAFETY INITIATIVE1. Multi disciplinary Advisory Council / 5 Topic Hospitals

2. Establish Best Practices through Rapid Cycle Improvement

3. Determine Outcomes / Metrics

4. Identify and Share Worker Safety Resources

(OSHA , LUCIAN LEAPE, CDC, NIOSH, TJC, LEAPT ENTITIES)

5. UPCOMING EVENTS:

- June 26, 2014 Coaching Call: Sharps Injury Prevention

- Team STEPPS Regional Training:

June 17-19, 2014 Cuscowilla on Lake Oconee

June 24-26, 2014 UGA Tifton Conference Center

July 8-10, 2014 GHA Education Center

- July 29, 2014 “Enhancing Caregiver Resilience”

- Ergonomic / Safe Patient Handling “Train the Trainer” Workshop (Date TBD)

PATIENT AND FAMILY ENGAGEMENT

PATIENT AND FAMILY ENGAGEMENT

1. Prior to admission, hospital staff provides and discusses a discharge planning check list with every patient that has a scheduled admission, allowing questions or comments from the patient or family.

2. Hospital conducts shift change huddles and does bedside reporting with patients and family members in all feasible cases.

3. Hospital has a person or functional area, who may also operate within other roles in the hospital, that is dedicated and proactively responsible for Patient and Family Engagement and systematically evaluates Patient and Family Engagement activities.

4. Hospital has an active Patient and Family Engagement Committee OR at least one former patient that serves on a patient safety or quality improvement committee or team.

5. Hospital has at least one or more patient(s) who serve on a governing or leadership board and serves as a patient representative.

LEADERSHIP

MARK YOUR CALENDAROBAE Affinity Call – June 25

PFE/PFCC Learning and Action Collaborative- In-Person June 25

Regional TeamSTEPPS Train the Trainer 2 ½ day Sessions June 24-26 UGA Tifton Conference Center 15 RDC Road Tifton, GA July 8-10 GHA Educational Center – wait list only

Georgia Hospital Association Summer Annual Meeting – July 8-11

Data and Assessment Submission Deadlines:

• Leadership and Patient and Family Engagement Assessment – June 30

• HEN HAC, EED, and HAI – May data due July 15th

 Next Coaching Call – July 16, 2014

Don’t forget your evaluation: : http://survey.gha.org/n/cohort234061814.aspx