HEN 2.0 and The IHA Institute Road AheadIMPROVING PATIENT SAFETY ACROSS ILLINOIS

May 5, 2015

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IHA Institute HEN Team

Jay D. Bhatt, DO, MPH, MPA, FACPChief Health Officer, Illinois Hospital Association

Cathy N. Grossi, JD, BSN, CPHQVice President, Institute for Innovations in Care and Quality

Helga Brake, PharmD, CPHQ, CPPSSenior Director, Institute for Innovations in Care and Quality

Marchelle Djordjevic, MBA, CPHQDirector, Institute for Innovations in Care and Quality

Adam Kohlrus, MS, CPHQ, CPPSDirector, Institute for Innovations in Care and Quality

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Marsha CurtisManager, Institute for Innovations in Care and Quality

Tammy De LeonardisAdministrative Assistant, Institute for Innovations in Care and Quality

IHA Institute HEN Team

The HEN wouldn’t cluck without support from our amazing administrative staff!

As part of HEN 1.0, 100 IL IHA HEN hospitals prevented 15,887 instances of patient harm for a cost savings of

$161.8 million between January 2012 and March 2014 14,294 readmissions prevented; 285 early-elective deliveries prevented; 234 post-operative pulmonary embolisms

or incidents of deep vein thrombosis prevented;

192 central line-associated bloodstream infections prevented;

188 catheter-associated urinary tract infections prevented;

152 incidents of ventilator-associated pneumonia prevented;

131 surgical site infections prevented; 126 birth trauma or injuries to neonates

prevented; 123 pressure ulcers prevented; 116 falls with injury prevented; and 46 manifestations of poor glycemic control

prevented.

http://www.ihatoday.org/IHA-Institute/Raising-the-Bar.aspx 4

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  AHA/HRET: Achievement of Targets – November 2014

AREA At least 60% Reporting

At least 70% Reporting

At least 80% Reporting

17.6% Change from Baseline (15% Readm) AND At Least

60% Reporting

40% Change from Baseline (20% Readm)

AND At Least 80% Reporting

Met High Perf.

Benchmk

Achievement of Target

ADE ü          

CAUTI ü ü ü100% reporting

ü33% reduction

   

CLABSI ü ü ü100% reporting

 ü61% reduction

  ü

Falls ü ü ü60%-53% reporting

ü9% reduction/25% reduction

     

OB-EED ü ü ü90% reporting

ü 79% reduction

  ü

OB-Other ü ü ü98% reporting

 ü 41% reduction 

  ü 

PrU ü ü ü100% reporting

ü28% reduction ü 

SSI ü ü ü100% reporting

 

Readm ü ü ü100% reporting

 

VAP/VAE ü üü

100% reporting 

ü 23% reduction 

     

VTE ü ü ü100% reporting

 ü42% reduction

   ü

IL IHA HEN 1.0 Results

CMS Partnership for Patients Hospital Engagement Network 2.0

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“The Hospital Engagement Network (HEN) will engage the hospital, provider and broader caregiver communities to quickly implement well-tested, evidence-based harm and measured best practices… the end result of the overall initiative shall be reduction in hospital-based harm and preventable readmissions.”

“Overall participation goal remains to recruit active participation of 100% of short-stay, acute care hospitals in the U.S.”

• HEN 2.0 Request for Proposal announced on February 11, 2015• Request for Proposal response submitted on March 30, 2015• Anticipate funding and contract awards in third quarter (July) 2015• 12-month contract

IHA Institute’s Primary Goal

To Provide the Highest Degree of Sustainable Value forIllinois Hospitals

Prime Contractor selection criteria:1. Dedicated to the implementation of evidence-based best

practices

2. Utilizes proven methods to decrease hospital-acquired conditions and improve patient safety culture

3. Access to hospital, state and national patient safety experts

4. Strongly supports minimum data collection and reporting burden philosophy

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Announcing!MHA-IHA HEN Partnership• Should HEN 2.0 be funded and contracts awarded, IHA will be

subcontracting with the Michigan Hospital Association’s (MHA) Keystone Center for the HEN 2.0 contract

• MHA’s Keystone Center successfully facilitated their own HEN from 2012-2014 and was among the top HENs in the country from a performance perspective (ACT score)

• While we had an amazing experience with AHA, we know that subcontracting with MHA will put our IL hospitals in the most optimal and sustainable position during the HEN 2.0 year and moving forward beyond HEN

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HEN 2.0 Focus Areas– Same as HEN 1.0 (40%/20% Reductions)

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Catheter-associated urinary tract infections (CAUTI), in all hospital settings, including avoiding placement of catheters both in the ER and in the hospital

Central line-associated blood stream infections (CLABSI), in all hospital settings, not only in ICUs

Ventilator-Associated Events (VAE), to include Infection-related Ventilator-Associated Complication (iVAC) and Ventilator-Associated Conditions (VAC)

Surgical site infections, to include measurement and improvement of SSI for multiple classes of surgeries

Obstetrical adverse events, including early elective delivery, obstetrical hemorrhage, and preeclampsia treatment and management to prevent maternal morbidity and mortality

Adverse drug events (ADE)• Participating hospitals that have a primarily adult population must report

measures related to opioid safety, anticoagulation safety and glycemic management, at a minimum

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ReadmissionsInjuries from falls and immobilityPressure ulcers Venous thromboembolism (VTE), including, at a minimum, all surgical settings

Additional topics for consideration• Severe Sepsis and Septic Shock• Hospital Culture of Safety (fully integrating patient safety with worker safety)• Iatrogenic Delirium• Clostridium Difficile (C.Dif.), including antibiotic stewardship• Undue Exposure to Radiation• Airway Safety• Failure to Rescue

HEN 2.0 Focus Areas– Same as HEN 1.0 (40%/20% Reductions)

Minimum Participation4 Requirements1. Signed Commitment Letter (HEN Lead, CEO, CMO, CNO)

2. Submission of monthly data set• 30 measures in all, includes 6 Hospital directly reported• Baseline year: 2010

3. Signed Data Use Agreement

4. Engagement in foundational education focused on Culture, High Reliability, and Patient and Family Engagement initiatives (Specifics TBD-meaningful, value added education)

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MHA-IHA HEN Participation Benefits

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1. Access to high-quality resources, tools, webinars, and other materials to support your improvement work on the HEN

2. Access to a data system to track progress on all applicable topics including reports

3. Access to national subject matter experts who can assist with improvement questions and recommendations

4. Opportunities to network, in-person and virtual, and access to shared forums to assist improvement teams with barriers and provide encouragement to continue the improvement journey

5. Opportunity to train staff in Quality Improvement principles through the QHR “Quality Boot Camp” at no cost

6. Opportunity to train and certify staff in patient safety, healthcare quality, and infection prevention (CPPS/CPHQ/CIC) at no cost

7. Opportunity to engage a physician from your organization in training and certification through the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP)

8. Opportunity to compete for 1 of 20 slots in our “Go to the IHI on the IHA” friendly competition

9. The Quality Department of your organization will receive a direct financial incentive when you return the commitment letter and DUA to IHA with HEN Lead, CEO, CMO, & CNO signatures within 60 days of receiving it

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MHA-IHA HEN Participation(even more) Benefits

MHA-IHA Approach to HEN 2.0

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Deeper Dive into the MHA-IHA CollaborativesStructure – Kick-off in-person meeting, followed by monthly webinars and

coaching calls with national experts. Each collaborative collects baseline and monthly data to ensure progress is made and sustained.

Collaboratives utilize the Johns Hopkins University 4Es methodology:Engage: Share stories and baseline data that show how the project will

improve culture and patient outcomes. Educate: Educate staff on evidence and interventions needed for change to

occur. Execute: Standardize procedures, create independent checks, learn from

mistakes and empower staff to pause a procedure if they see a potential error, safety or quality issue.

Evaluate: View infections or harm as defects in care and provide feedback on performance.

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Polling Question

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If you were to join the MHA-IHA HEN, would you be interested in participating in the CAUTI Keystone collaborative during HEN 2.0?

Interventions: assess current Foley catheter practices, implement CAUTI reduction practices, and educate staff and patients

1. Yes2. Maybe3. Doubt it4. No

Polling Question

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If you were to join the MHA-IHA HEN, would you be interested in participating in the PAIN MANAGEMENT Keystone collaborative during HEN 2.0?

Objectives: to address appropriate pain management in the hospital setting and decrease the usage of opiates statewide

1. Yes2. Maybe3. Doubt it4. No

Polling Question

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If you were to join the MHA-IHA HEN, would you be interested in participating in the OBSTETRICS Keystone collaborative during HEN 2.0?

Focuses on reducing risk of/and maternal and neonatal morbidity and mortality related to postpartum hemorrhage and preeclampsia

1. Yes2. Maybe3. Doubt it4. No

Polling Question

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If you were to join the MHA-IHA HEN, would you be interested in participating in the National CUSP 4 MVP-VAP Keystone collaborative during HEN 2.0?

Objective: to reduce ventilator- associated events in hospitals using proven effective interventions

1. Yes2. Maybe3. Doubt it4. No

Polling Question

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If you were to join the MHA-IHA HEN, would you be interested in participating in the ICU SEPSIS Keystone collaborative during HEN 2.0?

Objectives: prevent harm through implementation of bundles of interventions that ensure patients receive appropriate treatment for their condition and reduce the likelihood that a patient will die from severe sepsis or septic shock

1. Yes2. Maybe3. Doubt it4. No

Polling Question

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If you were to join the MHA-IHA HEN, would you be interested in participating in the ICU DELIRIUM AND EARLY MOBILITY Keystone collaborative during HEN 2.0?

Interventions include: delirium assessment/management, and identification and management of progressive mobility

1. Yes2. Maybe3. Doubt it4. No

6 Hospital Directly-Reported Measures:OB-EED (JC PC-01), Post-Partum Hemorrhage (JC/ACOG/CMQCC)ADE-Anticoagulant, Hypoglycemic, OpioidFalls-Falls with injury (NQF 0202)

HEN 2.0 Data Reporting30 required measures

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10 Measures reported for you by IHA’s

CompDataADE-1 OB-3 Pressure

Ulcer-1Readmits-

3 VTE-1 Sepsis-1

14 Measures reported for you by conferring

rights to MHA-IHACAUTI-

3CLABSI-

3 SSI-4 VAE-2 C.Dif-1 MRSA - 1

6 Hospital directly-reported measures ADE-3 Falls-1 OB-EED

& PPH

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Data Platform

• Bye bye CDS!

• MHA has contracted with Battelle, a 501(c)(3) charitable trust to develop our data platform

• We are in the process of working with Battelle to develop reports and portal functionality

• Hospitals will still enter numerator/denominator data and be able to run reports

Battelle is the world’s largest nonprofit research and

development organization. Battelle was founded on

industrialist Gordon Battelle’s vision that business and scientific interests can go hand-in-hand as forces for

positive change.

HEN 2.0 Commitment Letter

Eligibility and Recruitment: CMS is strongly urging 100 percent of short-stay, acute care U.S. hospitals to participate. As with HEN 1.0, hospitals are eligible to join any HEN but they may only join one HEN. A letter of engagement committing the organization to one HEN must be signed by the participating organization’s CEO and other C-suite executive sponsors within 60 days of project start.

• A commitment letter will be sent out once CMS funds the project and the primary contracts are awarded requiring signatures from the HEN Lead, CEO, CMO and CNO.

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MHA-IHA HEN

• Our aim in HEN 2.0 is to provide you with an enhanced level of resources, networking and coaching to assist you in advancing your Quality Improvement and Patient Safety agendas

• IHA and MHA staff are hard at work planning an array of content webinars and educational opportunities that will cover all 11 focus areas in HEN 2.0

• We are committed to providing you with a highly valued and successful initiative that will help IL hospitals meet and exceed national goals for the HEN year and beyond

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Partnering Across the Continuum…

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Next Steps…

• Signed Commitment Letter & Data Use Agreement• You will receive the documents after the project is funded

and the contracts are awarded (Quarter 3, 2015)• Commitment letter & Data Use Agreement signatures must

be obtained within 60 days to receive the financial incentive

• Look for the monthly Institute Insights newsletter to keep you informed. Contact TDeLeonardis@ihastaff.org to add yourself

• HEN 2.0 Metrics• Full list of 30 metrics available upon request

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One Final Polling Question

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Are you interested in joining the MHA-IHA HEN in 2015-2016?

1. Yes2. Maybe3. Doubt it4. No

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Thank you

Questions?

Adam KohlrusDirector, Performance Improvement IHA, akohlrus@ihastaff.org 217-541-1181