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Hospital Improvement Innovation Network
Amanda Keilholz CPHQ
Program Manager
March 27 2018
1
Agenda
Readmissions Case Study
Readmissions Data Update
Whatrsquos Coming after HIIN
Missouri Harm Dashboards
HIIN Regional Boot Camps
HIIN Project Updates
HRETHIIN Virtual Events
Upcoming Events
Resources
2
3
Readmissions Quality Improvement Case Study
Bethany Brandt RN BSN
SSM Health St Maryrsquos Hospital mdashJefferson City
Mission
Through our exceptional health care services we reveal the healing presence of God
The hospital moved to a new state-of-the-art building in 2014 and features an evidence-based design that focuses on healing environments and patient safety
We serve patients in need of emergency cardiology orthopedic cancer maternity and medical imaging services
4
SSM Healthrsquos Quality Principles
Patients and other customers are our first priority
Quality is achieved through people
All work is part of a process
Decision-making by facts
Quality requires continuous quality improvement
5
ProblemReason for Action
Overall readmission rate is a component of Value Based Purchasing and is used to determine financial penalties that may or may not occur from CMS
At SSM St Maryrsquos Hospital Jefferson City our objective is to be better than the expected rate of CMS readmissions This would in turn prevent us from receiving a penalty and allow us to obtain dollars that are left on the CMS table while enhancing patient experience and outcomes in high risk patient populations
6
Goal
A goal of 81 has been set for all cause readmissions for our facility
With a focus on AMI (acute myocardial infarction) CABG (coronary artery bypass grafting) HF (heart failure) COPD (chronic obstructive pulmonary disease) and PN (pneumonia) readmissions
7
Future State
Goal is to avoid hospital readmissions and increase our patientrsquos quality of life
Improving patient outcomes is the ultimate goal of hospital quality improvement
Gap Analysis
Current State
Focus on all cause readmissions for high risk patient populations with the following diagnoses
ndash HF
ndash AMI
ndash CABG
ndash COPD
ndash Pneumonia
8
Improving Quality of Care and Reducing Readmissions
Improvement of 3 month rolling heart failure readmission rate from 206 in March 2017 to 14 in July 2017
Improvement of 12 month rolling COPD readmission rate from 183 in August 2016 to 152 in August 2017
Improvement of 3 month rolling COPD readmission rate from 206 in May of 2017 to 47 in August 2017
9
Improving Quality of Care and Reducing Readmissions
Improvement of 12 month rolling pneumonia readmission rate from 133 in May 2016 to 101 in April 2017
Maintained 12 month rolling CABG readmission rate below the premier benchmark of 79
10
All Cause Readmission
11
AMI Readmission
12
CABG Readmission
13
HF Readmission
14
COPD Readmission
15
Pneumonia Readmission
16
Solution Approach
Patients are risk stratified per the Modified Lace Tool
Focus is on high risk patients
Disease specific education with daily teach back method
Nursing Home Collaboration for high risk heart failure patients
Transition Care Nurses make visits to local nursing homes
SSM Home Connections visits to nursing homes in rural nursing homes
17
Solution Approach
Pharmacy admission and discharge medication reconciliation and disease specific education
Multi-disciplinary discharge planning on admission
Standing orderset used to place appropriate consults
Daily flash rounds to discuss discharge planning with a multidisciplinary team
18
Solution Approach
Daily meeting with SSM Home Health to review high risk patients
Daily assessment and report potential hazards for readmission to physician
Structured telephone program
Data collection to track leading indicators
Daily readmission report out for the GEMBA program
Weekly readmission RCA
19
Solution Approach
Weekly Core Team Meetings
Implemented on 21517 and ongoing currently
Root cause analysis on each readmission with action planinitiatives reviewedimplemented
Review status on all nursing home patientsvisits and address concerns and identify opportunities
Review at risk patients that are at home and address concerns and identify opportunities
Review leading and lagging indicators and address concerns and identify opportunities
Update on current corrective actions20
Test of ChangeRapid Experiment
Follow up appointment with physician within 5 business days to 100 in 2017
Improve patient actually attending the follow up appointment to 100 in 2017
Home health visits within 24 hours with front loading of visits 100 in 2017
Improve Medication Reconciliation on admission and discharge for all 5 diseases to 100 in 2017
21
Completion Plan
As of June 2017 scales can be provided for low income heart failure patients upon discharge
20172018 Development Projects
Robust palliative care program
Meal delivery program
Rescue Clinic
Improve physician engagement
Enhanced collaboration with LSS and Stonebridge (Quarterly meetings scheduled)
Palliative Care Program (Sub Team developing proposal)
Consider Code HF program (ED Implementation)
22
Confirmed State
Decrease HF readmissions from 202 in 2016 to 153 in 2017
Decrease COPD readmissions 198 in 2016 to 144 in 2017
Decrease PN readmissions from 122 in 2016 to 114 in 2017
Maintain AMI and CABG readmissions at better than the 90th percentile in 2017
23
Questions
24
Readmissions UpdateJosh Grotzinger
25
ICD-10 Readmission Update
October 2015 HIDI developed a GEM-mapped approach to the CMSYale risk-adjusted readmission models to accommodate ICD-9 and ICD-10 codes This action was taken prior to the availability of final ICD-910 compliant models from CMSYale to ensure continuity of readmission reporting for HIDI-participating hospitals
CMSYale released new ICD-910 compliant risk-adjusted readmission models with the release of the 2017 Hospital Compare data
26
CMSYale Documentation
CMSYale have validated their ICD-910 compliant models with documentation on QualityNet
Documentation on additionsexclusions from the cohort definitions are available through CMSYale on QualityNet
HIDI observed very modest levels of variation between the readmission models (HIDI GEM-mapped and CMSYale ICD-910 compliant)
27
Whatrsquos Coming after HIINJessica Stultz
28
Missouri Harm Dashboard
29
Missouri Harm Dashboard
MHA board initiative
Three harms
CAUTI
CLABSI
CDI
Reduce state rate by 10 percent
30
Missouri Harm Dashboard
All Missouri acute care hospitals
Excludes rehab psych LTAC womenrsquos childrens specialty veteransmilitary
Distributed to CEOs quarterly
2017 Q4 dashboard was distributed at district council last week
Targeted education materials to be sent at the leadership level
31
Missouri Harm Dashboard
Includes NHSN data only
Measuring improvement of rates
Most recent SIR will be shown on dashboard
Measuring improvement over state target
Calendar year 2016 baseline
Data will be pulled quarterly
2017 Q4 distributed March 2018
2018 Q1 will be distributed June 2018
32
33
HIIN Regional Boot Camps
To Increase Workersrsquo Safety
34
What to Expect
Attendees will be taught and have the opportunity to demonstrate
De-escalation management
Crisis intervention training to supplement the de-escalation techniques with a focus on mental health populations
Components of rape aggression defense training will be taught to offer realistic self-defense tactics and techniques
35
What to Expect
A holistic approach to reducing both the risk and anxiety surrounding violence in healthcare
Excellent supplement to existing safety programs already in place at your organizations
Offered at no cost to Missouri HRET-HIIN hospitals
Audience
front line staff in all care units (ED critical care and medical-surgical units)
safety and security personnel36
Locations and Times
Workplace safety
Blue Springs
ndash April 11 2018 at the Courtyard Marriott ndash Adams Pointe Conference Center
Springfield
ndash April 25 2018 at the Oasis Hotel and Convention Center
St Charles
ndash May 2 2018 at the Embassy Suites Hotel
Cape Girardeau
ndash May 9 2018 at the Drury Plaza Hotel Conference Center
37
HIIN Project Updates
38
Data Due Dates mdash HIIN Project Year 2
39
MHA ldquoZero Heroesrdquo Club
MHA congratulates the following HIIN-participating hospitals with the most zero harm measures reported These organizations have either achieved andor sustained a zero rate of harm and are in the top 10 percent of HIIN-participating hospitals Congratulations to the ldquoZero Herosrdquo for the month of September
Carroll County Memorial Hospital
Ellett Memorial Hospital
Harrison County Community Hospital
Iron County Medical Center
Osage Beach Center for Cognitive Disorders
Pike County Memorial Hospital
Southeast Health Center of Ripley County
Sullivan County Memorial Hospital
40
AHArsquos IT department investigated the emails and discovered they were generated by groups from Germany and Switzerland AHA recommends that your IT department block emails from these two countries unless you do business with them
SPAM Email from HEN or HIIN Finance mdash PLEASE IGNORE
If you receive an email asking you to pay your invoice via a link please ignore and permanently delete Do not click on the link in the email The email may come from different email addresses but is titled as HENHIIN Finance or HRET HIIN similar to what is pictured below
41
Hospital Leadership and Quality Assessment Tool
The tool measures board members C-suite executives and managementsupervisors on how well they are implementing evidence-based practices shown to support a culture of safety and high performance in clinical quality measures
No front-line staff survey component
Survey content
FAQ
42
HLQAT Survey
MHA is providing this complimentary opportunity for all HIIN hospitals to access and utilize this survey
Two options
Phase I mdash Completed
Phase II mdash April through August 2018
ndash Available to all HIIN hospitals mdash previous participation not
required
ndash Phase I hospitals may participate in phase II if desired
ndash Intent to participate materials will be sent to HIIN contacts soon
43
Qualaris Audit Tool Projects
Hand Hygiene
Culture of Safety Rounding
Sepsis
ReadmissionsCare Transitions
44
Qualaris mdash New Tools
Qualaris has new tools to assist users with coordinating successful improvement projects
Tracking project outcomes alongside process measures
Real-time dashboards inclusive of both outcomes and process measures
Documenting PDSAs
Click here to view the Qualaris improvement projects and outcomes demo
These tools require a short setup webinar session with Qualaris
Readmission Immersion Project participants should contact supportqualariscom
Use the Qualaris virtual chat support for next steps
45
LEAN Six Sigma Green Belt Project
Project launching mdashMarch 13 2018 through November 30 2018
Hospitals committed mdash20
Topic-focused
Patient throughput
ICU harm reduction
Errors in medication reconciliation
46
Capital Region Medical Center
Carroll County Memorial Hospital
Cass Regional Medical Center
Cox Medical Center
Fitzgibbon Hospital
Golden Valley Memorial Healthcare
Hannibal Regional Hospital
Lafayette Regional Health Center
Lake Regional Health System
Liberty Hospital
North Kansas City Hospital
Ozark Medical Center
Perry County Memorial Hospital
Saint Lukes Health System
Saint Lukes Hospital Kansas City
Scotland County Hospital
Southeast Missouri Hospital
St Marys Medical Center
Ste Genevieve County Memorial Hospital
Western Missouri Medical Center
NHSN Reporting Facilities
The January 23rd release of the NHSN 881 application will introduce an updated NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled in NHSN prior to December 2 2017 Facilities that enrolled in NHSN on or after December 2 2017 have already accessed this new Consent and will not need to accept it again if they have already done so
Primary Contacts or Facility Administrators should agree to this updated Consent form for each component by April 14th 2018 or risk losing access to NHSN
An alert will appear on all NHSN component home pages and primary contacts and facility administrators will receive an email notification
Additional information including Frequently Asked Questions and the updated NHSN purposes are available on CDCs NHSN website If you have any questions please send an email to NHSNcdcgov with the subject line ldquoNHSN Reconsentrdquo
47
NHSN Reporting Facilities
The NHSN team has published informational guidance on our website to assist users with completion of the updated NHSN Agreement to Participate and Consent A 5-minute video informs users of the new Consent purposes and the simple process for accepting the Consent electronically Furthermore a step-by-step guidance document provides detailed instructions and screen shots for what Facility Administrators and Primary Contacts can expect to see when they begin the re-consent process in the NHSN application A link to the video and the guidance document can both be found in the FAQs About NHSNrsquos Agreement to Participate and Consent
48
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
Agenda
Readmissions Case Study
Readmissions Data Update
Whatrsquos Coming after HIIN
Missouri Harm Dashboards
HIIN Regional Boot Camps
HIIN Project Updates
HRETHIIN Virtual Events
Upcoming Events
Resources
2
3
Readmissions Quality Improvement Case Study
Bethany Brandt RN BSN
SSM Health St Maryrsquos Hospital mdashJefferson City
Mission
Through our exceptional health care services we reveal the healing presence of God
The hospital moved to a new state-of-the-art building in 2014 and features an evidence-based design that focuses on healing environments and patient safety
We serve patients in need of emergency cardiology orthopedic cancer maternity and medical imaging services
4
SSM Healthrsquos Quality Principles
Patients and other customers are our first priority
Quality is achieved through people
All work is part of a process
Decision-making by facts
Quality requires continuous quality improvement
5
ProblemReason for Action
Overall readmission rate is a component of Value Based Purchasing and is used to determine financial penalties that may or may not occur from CMS
At SSM St Maryrsquos Hospital Jefferson City our objective is to be better than the expected rate of CMS readmissions This would in turn prevent us from receiving a penalty and allow us to obtain dollars that are left on the CMS table while enhancing patient experience and outcomes in high risk patient populations
6
Goal
A goal of 81 has been set for all cause readmissions for our facility
With a focus on AMI (acute myocardial infarction) CABG (coronary artery bypass grafting) HF (heart failure) COPD (chronic obstructive pulmonary disease) and PN (pneumonia) readmissions
7
Future State
Goal is to avoid hospital readmissions and increase our patientrsquos quality of life
Improving patient outcomes is the ultimate goal of hospital quality improvement
Gap Analysis
Current State
Focus on all cause readmissions for high risk patient populations with the following diagnoses
ndash HF
ndash AMI
ndash CABG
ndash COPD
ndash Pneumonia
8
Improving Quality of Care and Reducing Readmissions
Improvement of 3 month rolling heart failure readmission rate from 206 in March 2017 to 14 in July 2017
Improvement of 12 month rolling COPD readmission rate from 183 in August 2016 to 152 in August 2017
Improvement of 3 month rolling COPD readmission rate from 206 in May of 2017 to 47 in August 2017
9
Improving Quality of Care and Reducing Readmissions
Improvement of 12 month rolling pneumonia readmission rate from 133 in May 2016 to 101 in April 2017
Maintained 12 month rolling CABG readmission rate below the premier benchmark of 79
10
All Cause Readmission
11
AMI Readmission
12
CABG Readmission
13
HF Readmission
14
COPD Readmission
15
Pneumonia Readmission
16
Solution Approach
Patients are risk stratified per the Modified Lace Tool
Focus is on high risk patients
Disease specific education with daily teach back method
Nursing Home Collaboration for high risk heart failure patients
Transition Care Nurses make visits to local nursing homes
SSM Home Connections visits to nursing homes in rural nursing homes
17
Solution Approach
Pharmacy admission and discharge medication reconciliation and disease specific education
Multi-disciplinary discharge planning on admission
Standing orderset used to place appropriate consults
Daily flash rounds to discuss discharge planning with a multidisciplinary team
18
Solution Approach
Daily meeting with SSM Home Health to review high risk patients
Daily assessment and report potential hazards for readmission to physician
Structured telephone program
Data collection to track leading indicators
Daily readmission report out for the GEMBA program
Weekly readmission RCA
19
Solution Approach
Weekly Core Team Meetings
Implemented on 21517 and ongoing currently
Root cause analysis on each readmission with action planinitiatives reviewedimplemented
Review status on all nursing home patientsvisits and address concerns and identify opportunities
Review at risk patients that are at home and address concerns and identify opportunities
Review leading and lagging indicators and address concerns and identify opportunities
Update on current corrective actions20
Test of ChangeRapid Experiment
Follow up appointment with physician within 5 business days to 100 in 2017
Improve patient actually attending the follow up appointment to 100 in 2017
Home health visits within 24 hours with front loading of visits 100 in 2017
Improve Medication Reconciliation on admission and discharge for all 5 diseases to 100 in 2017
21
Completion Plan
As of June 2017 scales can be provided for low income heart failure patients upon discharge
20172018 Development Projects
Robust palliative care program
Meal delivery program
Rescue Clinic
Improve physician engagement
Enhanced collaboration with LSS and Stonebridge (Quarterly meetings scheduled)
Palliative Care Program (Sub Team developing proposal)
Consider Code HF program (ED Implementation)
22
Confirmed State
Decrease HF readmissions from 202 in 2016 to 153 in 2017
Decrease COPD readmissions 198 in 2016 to 144 in 2017
Decrease PN readmissions from 122 in 2016 to 114 in 2017
Maintain AMI and CABG readmissions at better than the 90th percentile in 2017
23
Questions
24
Readmissions UpdateJosh Grotzinger
25
ICD-10 Readmission Update
October 2015 HIDI developed a GEM-mapped approach to the CMSYale risk-adjusted readmission models to accommodate ICD-9 and ICD-10 codes This action was taken prior to the availability of final ICD-910 compliant models from CMSYale to ensure continuity of readmission reporting for HIDI-participating hospitals
CMSYale released new ICD-910 compliant risk-adjusted readmission models with the release of the 2017 Hospital Compare data
26
CMSYale Documentation
CMSYale have validated their ICD-910 compliant models with documentation on QualityNet
Documentation on additionsexclusions from the cohort definitions are available through CMSYale on QualityNet
HIDI observed very modest levels of variation between the readmission models (HIDI GEM-mapped and CMSYale ICD-910 compliant)
27
Whatrsquos Coming after HIINJessica Stultz
28
Missouri Harm Dashboard
29
Missouri Harm Dashboard
MHA board initiative
Three harms
CAUTI
CLABSI
CDI
Reduce state rate by 10 percent
30
Missouri Harm Dashboard
All Missouri acute care hospitals
Excludes rehab psych LTAC womenrsquos childrens specialty veteransmilitary
Distributed to CEOs quarterly
2017 Q4 dashboard was distributed at district council last week
Targeted education materials to be sent at the leadership level
31
Missouri Harm Dashboard
Includes NHSN data only
Measuring improvement of rates
Most recent SIR will be shown on dashboard
Measuring improvement over state target
Calendar year 2016 baseline
Data will be pulled quarterly
2017 Q4 distributed March 2018
2018 Q1 will be distributed June 2018
32
33
HIIN Regional Boot Camps
To Increase Workersrsquo Safety
34
What to Expect
Attendees will be taught and have the opportunity to demonstrate
De-escalation management
Crisis intervention training to supplement the de-escalation techniques with a focus on mental health populations
Components of rape aggression defense training will be taught to offer realistic self-defense tactics and techniques
35
What to Expect
A holistic approach to reducing both the risk and anxiety surrounding violence in healthcare
Excellent supplement to existing safety programs already in place at your organizations
Offered at no cost to Missouri HRET-HIIN hospitals
Audience
front line staff in all care units (ED critical care and medical-surgical units)
safety and security personnel36
Locations and Times
Workplace safety
Blue Springs
ndash April 11 2018 at the Courtyard Marriott ndash Adams Pointe Conference Center
Springfield
ndash April 25 2018 at the Oasis Hotel and Convention Center
St Charles
ndash May 2 2018 at the Embassy Suites Hotel
Cape Girardeau
ndash May 9 2018 at the Drury Plaza Hotel Conference Center
37
HIIN Project Updates
38
Data Due Dates mdash HIIN Project Year 2
39
MHA ldquoZero Heroesrdquo Club
MHA congratulates the following HIIN-participating hospitals with the most zero harm measures reported These organizations have either achieved andor sustained a zero rate of harm and are in the top 10 percent of HIIN-participating hospitals Congratulations to the ldquoZero Herosrdquo for the month of September
Carroll County Memorial Hospital
Ellett Memorial Hospital
Harrison County Community Hospital
Iron County Medical Center
Osage Beach Center for Cognitive Disorders
Pike County Memorial Hospital
Southeast Health Center of Ripley County
Sullivan County Memorial Hospital
40
AHArsquos IT department investigated the emails and discovered they were generated by groups from Germany and Switzerland AHA recommends that your IT department block emails from these two countries unless you do business with them
SPAM Email from HEN or HIIN Finance mdash PLEASE IGNORE
If you receive an email asking you to pay your invoice via a link please ignore and permanently delete Do not click on the link in the email The email may come from different email addresses but is titled as HENHIIN Finance or HRET HIIN similar to what is pictured below
41
Hospital Leadership and Quality Assessment Tool
The tool measures board members C-suite executives and managementsupervisors on how well they are implementing evidence-based practices shown to support a culture of safety and high performance in clinical quality measures
No front-line staff survey component
Survey content
FAQ
42
HLQAT Survey
MHA is providing this complimentary opportunity for all HIIN hospitals to access and utilize this survey
Two options
Phase I mdash Completed
Phase II mdash April through August 2018
ndash Available to all HIIN hospitals mdash previous participation not
required
ndash Phase I hospitals may participate in phase II if desired
ndash Intent to participate materials will be sent to HIIN contacts soon
43
Qualaris Audit Tool Projects
Hand Hygiene
Culture of Safety Rounding
Sepsis
ReadmissionsCare Transitions
44
Qualaris mdash New Tools
Qualaris has new tools to assist users with coordinating successful improvement projects
Tracking project outcomes alongside process measures
Real-time dashboards inclusive of both outcomes and process measures
Documenting PDSAs
Click here to view the Qualaris improvement projects and outcomes demo
These tools require a short setup webinar session with Qualaris
Readmission Immersion Project participants should contact supportqualariscom
Use the Qualaris virtual chat support for next steps
45
LEAN Six Sigma Green Belt Project
Project launching mdashMarch 13 2018 through November 30 2018
Hospitals committed mdash20
Topic-focused
Patient throughput
ICU harm reduction
Errors in medication reconciliation
46
Capital Region Medical Center
Carroll County Memorial Hospital
Cass Regional Medical Center
Cox Medical Center
Fitzgibbon Hospital
Golden Valley Memorial Healthcare
Hannibal Regional Hospital
Lafayette Regional Health Center
Lake Regional Health System
Liberty Hospital
North Kansas City Hospital
Ozark Medical Center
Perry County Memorial Hospital
Saint Lukes Health System
Saint Lukes Hospital Kansas City
Scotland County Hospital
Southeast Missouri Hospital
St Marys Medical Center
Ste Genevieve County Memorial Hospital
Western Missouri Medical Center
NHSN Reporting Facilities
The January 23rd release of the NHSN 881 application will introduce an updated NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled in NHSN prior to December 2 2017 Facilities that enrolled in NHSN on or after December 2 2017 have already accessed this new Consent and will not need to accept it again if they have already done so
Primary Contacts or Facility Administrators should agree to this updated Consent form for each component by April 14th 2018 or risk losing access to NHSN
An alert will appear on all NHSN component home pages and primary contacts and facility administrators will receive an email notification
Additional information including Frequently Asked Questions and the updated NHSN purposes are available on CDCs NHSN website If you have any questions please send an email to NHSNcdcgov with the subject line ldquoNHSN Reconsentrdquo
47
NHSN Reporting Facilities
The NHSN team has published informational guidance on our website to assist users with completion of the updated NHSN Agreement to Participate and Consent A 5-minute video informs users of the new Consent purposes and the simple process for accepting the Consent electronically Furthermore a step-by-step guidance document provides detailed instructions and screen shots for what Facility Administrators and Primary Contacts can expect to see when they begin the re-consent process in the NHSN application A link to the video and the guidance document can both be found in the FAQs About NHSNrsquos Agreement to Participate and Consent
48
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
3
Readmissions Quality Improvement Case Study
Bethany Brandt RN BSN
SSM Health St Maryrsquos Hospital mdashJefferson City
Mission
Through our exceptional health care services we reveal the healing presence of God
The hospital moved to a new state-of-the-art building in 2014 and features an evidence-based design that focuses on healing environments and patient safety
We serve patients in need of emergency cardiology orthopedic cancer maternity and medical imaging services
4
SSM Healthrsquos Quality Principles
Patients and other customers are our first priority
Quality is achieved through people
All work is part of a process
Decision-making by facts
Quality requires continuous quality improvement
5
ProblemReason for Action
Overall readmission rate is a component of Value Based Purchasing and is used to determine financial penalties that may or may not occur from CMS
At SSM St Maryrsquos Hospital Jefferson City our objective is to be better than the expected rate of CMS readmissions This would in turn prevent us from receiving a penalty and allow us to obtain dollars that are left on the CMS table while enhancing patient experience and outcomes in high risk patient populations
6
Goal
A goal of 81 has been set for all cause readmissions for our facility
With a focus on AMI (acute myocardial infarction) CABG (coronary artery bypass grafting) HF (heart failure) COPD (chronic obstructive pulmonary disease) and PN (pneumonia) readmissions
7
Future State
Goal is to avoid hospital readmissions and increase our patientrsquos quality of life
Improving patient outcomes is the ultimate goal of hospital quality improvement
Gap Analysis
Current State
Focus on all cause readmissions for high risk patient populations with the following diagnoses
ndash HF
ndash AMI
ndash CABG
ndash COPD
ndash Pneumonia
8
Improving Quality of Care and Reducing Readmissions
Improvement of 3 month rolling heart failure readmission rate from 206 in March 2017 to 14 in July 2017
Improvement of 12 month rolling COPD readmission rate from 183 in August 2016 to 152 in August 2017
Improvement of 3 month rolling COPD readmission rate from 206 in May of 2017 to 47 in August 2017
9
Improving Quality of Care and Reducing Readmissions
Improvement of 12 month rolling pneumonia readmission rate from 133 in May 2016 to 101 in April 2017
Maintained 12 month rolling CABG readmission rate below the premier benchmark of 79
10
All Cause Readmission
11
AMI Readmission
12
CABG Readmission
13
HF Readmission
14
COPD Readmission
15
Pneumonia Readmission
16
Solution Approach
Patients are risk stratified per the Modified Lace Tool
Focus is on high risk patients
Disease specific education with daily teach back method
Nursing Home Collaboration for high risk heart failure patients
Transition Care Nurses make visits to local nursing homes
SSM Home Connections visits to nursing homes in rural nursing homes
17
Solution Approach
Pharmacy admission and discharge medication reconciliation and disease specific education
Multi-disciplinary discharge planning on admission
Standing orderset used to place appropriate consults
Daily flash rounds to discuss discharge planning with a multidisciplinary team
18
Solution Approach
Daily meeting with SSM Home Health to review high risk patients
Daily assessment and report potential hazards for readmission to physician
Structured telephone program
Data collection to track leading indicators
Daily readmission report out for the GEMBA program
Weekly readmission RCA
19
Solution Approach
Weekly Core Team Meetings
Implemented on 21517 and ongoing currently
Root cause analysis on each readmission with action planinitiatives reviewedimplemented
Review status on all nursing home patientsvisits and address concerns and identify opportunities
Review at risk patients that are at home and address concerns and identify opportunities
Review leading and lagging indicators and address concerns and identify opportunities
Update on current corrective actions20
Test of ChangeRapid Experiment
Follow up appointment with physician within 5 business days to 100 in 2017
Improve patient actually attending the follow up appointment to 100 in 2017
Home health visits within 24 hours with front loading of visits 100 in 2017
Improve Medication Reconciliation on admission and discharge for all 5 diseases to 100 in 2017
21
Completion Plan
As of June 2017 scales can be provided for low income heart failure patients upon discharge
20172018 Development Projects
Robust palliative care program
Meal delivery program
Rescue Clinic
Improve physician engagement
Enhanced collaboration with LSS and Stonebridge (Quarterly meetings scheduled)
Palliative Care Program (Sub Team developing proposal)
Consider Code HF program (ED Implementation)
22
Confirmed State
Decrease HF readmissions from 202 in 2016 to 153 in 2017
Decrease COPD readmissions 198 in 2016 to 144 in 2017
Decrease PN readmissions from 122 in 2016 to 114 in 2017
Maintain AMI and CABG readmissions at better than the 90th percentile in 2017
23
Questions
24
Readmissions UpdateJosh Grotzinger
25
ICD-10 Readmission Update
October 2015 HIDI developed a GEM-mapped approach to the CMSYale risk-adjusted readmission models to accommodate ICD-9 and ICD-10 codes This action was taken prior to the availability of final ICD-910 compliant models from CMSYale to ensure continuity of readmission reporting for HIDI-participating hospitals
CMSYale released new ICD-910 compliant risk-adjusted readmission models with the release of the 2017 Hospital Compare data
26
CMSYale Documentation
CMSYale have validated their ICD-910 compliant models with documentation on QualityNet
Documentation on additionsexclusions from the cohort definitions are available through CMSYale on QualityNet
HIDI observed very modest levels of variation between the readmission models (HIDI GEM-mapped and CMSYale ICD-910 compliant)
27
Whatrsquos Coming after HIINJessica Stultz
28
Missouri Harm Dashboard
29
Missouri Harm Dashboard
MHA board initiative
Three harms
CAUTI
CLABSI
CDI
Reduce state rate by 10 percent
30
Missouri Harm Dashboard
All Missouri acute care hospitals
Excludes rehab psych LTAC womenrsquos childrens specialty veteransmilitary
Distributed to CEOs quarterly
2017 Q4 dashboard was distributed at district council last week
Targeted education materials to be sent at the leadership level
31
Missouri Harm Dashboard
Includes NHSN data only
Measuring improvement of rates
Most recent SIR will be shown on dashboard
Measuring improvement over state target
Calendar year 2016 baseline
Data will be pulled quarterly
2017 Q4 distributed March 2018
2018 Q1 will be distributed June 2018
32
33
HIIN Regional Boot Camps
To Increase Workersrsquo Safety
34
What to Expect
Attendees will be taught and have the opportunity to demonstrate
De-escalation management
Crisis intervention training to supplement the de-escalation techniques with a focus on mental health populations
Components of rape aggression defense training will be taught to offer realistic self-defense tactics and techniques
35
What to Expect
A holistic approach to reducing both the risk and anxiety surrounding violence in healthcare
Excellent supplement to existing safety programs already in place at your organizations
Offered at no cost to Missouri HRET-HIIN hospitals
Audience
front line staff in all care units (ED critical care and medical-surgical units)
safety and security personnel36
Locations and Times
Workplace safety
Blue Springs
ndash April 11 2018 at the Courtyard Marriott ndash Adams Pointe Conference Center
Springfield
ndash April 25 2018 at the Oasis Hotel and Convention Center
St Charles
ndash May 2 2018 at the Embassy Suites Hotel
Cape Girardeau
ndash May 9 2018 at the Drury Plaza Hotel Conference Center
37
HIIN Project Updates
38
Data Due Dates mdash HIIN Project Year 2
39
MHA ldquoZero Heroesrdquo Club
MHA congratulates the following HIIN-participating hospitals with the most zero harm measures reported These organizations have either achieved andor sustained a zero rate of harm and are in the top 10 percent of HIIN-participating hospitals Congratulations to the ldquoZero Herosrdquo for the month of September
Carroll County Memorial Hospital
Ellett Memorial Hospital
Harrison County Community Hospital
Iron County Medical Center
Osage Beach Center for Cognitive Disorders
Pike County Memorial Hospital
Southeast Health Center of Ripley County
Sullivan County Memorial Hospital
40
AHArsquos IT department investigated the emails and discovered they were generated by groups from Germany and Switzerland AHA recommends that your IT department block emails from these two countries unless you do business with them
SPAM Email from HEN or HIIN Finance mdash PLEASE IGNORE
If you receive an email asking you to pay your invoice via a link please ignore and permanently delete Do not click on the link in the email The email may come from different email addresses but is titled as HENHIIN Finance or HRET HIIN similar to what is pictured below
41
Hospital Leadership and Quality Assessment Tool
The tool measures board members C-suite executives and managementsupervisors on how well they are implementing evidence-based practices shown to support a culture of safety and high performance in clinical quality measures
No front-line staff survey component
Survey content
FAQ
42
HLQAT Survey
MHA is providing this complimentary opportunity for all HIIN hospitals to access and utilize this survey
Two options
Phase I mdash Completed
Phase II mdash April through August 2018
ndash Available to all HIIN hospitals mdash previous participation not
required
ndash Phase I hospitals may participate in phase II if desired
ndash Intent to participate materials will be sent to HIIN contacts soon
43
Qualaris Audit Tool Projects
Hand Hygiene
Culture of Safety Rounding
Sepsis
ReadmissionsCare Transitions
44
Qualaris mdash New Tools
Qualaris has new tools to assist users with coordinating successful improvement projects
Tracking project outcomes alongside process measures
Real-time dashboards inclusive of both outcomes and process measures
Documenting PDSAs
Click here to view the Qualaris improvement projects and outcomes demo
These tools require a short setup webinar session with Qualaris
Readmission Immersion Project participants should contact supportqualariscom
Use the Qualaris virtual chat support for next steps
45
LEAN Six Sigma Green Belt Project
Project launching mdashMarch 13 2018 through November 30 2018
Hospitals committed mdash20
Topic-focused
Patient throughput
ICU harm reduction
Errors in medication reconciliation
46
Capital Region Medical Center
Carroll County Memorial Hospital
Cass Regional Medical Center
Cox Medical Center
Fitzgibbon Hospital
Golden Valley Memorial Healthcare
Hannibal Regional Hospital
Lafayette Regional Health Center
Lake Regional Health System
Liberty Hospital
North Kansas City Hospital
Ozark Medical Center
Perry County Memorial Hospital
Saint Lukes Health System
Saint Lukes Hospital Kansas City
Scotland County Hospital
Southeast Missouri Hospital
St Marys Medical Center
Ste Genevieve County Memorial Hospital
Western Missouri Medical Center
NHSN Reporting Facilities
The January 23rd release of the NHSN 881 application will introduce an updated NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled in NHSN prior to December 2 2017 Facilities that enrolled in NHSN on or after December 2 2017 have already accessed this new Consent and will not need to accept it again if they have already done so
Primary Contacts or Facility Administrators should agree to this updated Consent form for each component by April 14th 2018 or risk losing access to NHSN
An alert will appear on all NHSN component home pages and primary contacts and facility administrators will receive an email notification
Additional information including Frequently Asked Questions and the updated NHSN purposes are available on CDCs NHSN website If you have any questions please send an email to NHSNcdcgov with the subject line ldquoNHSN Reconsentrdquo
47
NHSN Reporting Facilities
The NHSN team has published informational guidance on our website to assist users with completion of the updated NHSN Agreement to Participate and Consent A 5-minute video informs users of the new Consent purposes and the simple process for accepting the Consent electronically Furthermore a step-by-step guidance document provides detailed instructions and screen shots for what Facility Administrators and Primary Contacts can expect to see when they begin the re-consent process in the NHSN application A link to the video and the guidance document can both be found in the FAQs About NHSNrsquos Agreement to Participate and Consent
48
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
SSM Health St Maryrsquos Hospital mdashJefferson City
Mission
Through our exceptional health care services we reveal the healing presence of God
The hospital moved to a new state-of-the-art building in 2014 and features an evidence-based design that focuses on healing environments and patient safety
We serve patients in need of emergency cardiology orthopedic cancer maternity and medical imaging services
4
SSM Healthrsquos Quality Principles
Patients and other customers are our first priority
Quality is achieved through people
All work is part of a process
Decision-making by facts
Quality requires continuous quality improvement
5
ProblemReason for Action
Overall readmission rate is a component of Value Based Purchasing and is used to determine financial penalties that may or may not occur from CMS
At SSM St Maryrsquos Hospital Jefferson City our objective is to be better than the expected rate of CMS readmissions This would in turn prevent us from receiving a penalty and allow us to obtain dollars that are left on the CMS table while enhancing patient experience and outcomes in high risk patient populations
6
Goal
A goal of 81 has been set for all cause readmissions for our facility
With a focus on AMI (acute myocardial infarction) CABG (coronary artery bypass grafting) HF (heart failure) COPD (chronic obstructive pulmonary disease) and PN (pneumonia) readmissions
7
Future State
Goal is to avoid hospital readmissions and increase our patientrsquos quality of life
Improving patient outcomes is the ultimate goal of hospital quality improvement
Gap Analysis
Current State
Focus on all cause readmissions for high risk patient populations with the following diagnoses
ndash HF
ndash AMI
ndash CABG
ndash COPD
ndash Pneumonia
8
Improving Quality of Care and Reducing Readmissions
Improvement of 3 month rolling heart failure readmission rate from 206 in March 2017 to 14 in July 2017
Improvement of 12 month rolling COPD readmission rate from 183 in August 2016 to 152 in August 2017
Improvement of 3 month rolling COPD readmission rate from 206 in May of 2017 to 47 in August 2017
9
Improving Quality of Care and Reducing Readmissions
Improvement of 12 month rolling pneumonia readmission rate from 133 in May 2016 to 101 in April 2017
Maintained 12 month rolling CABG readmission rate below the premier benchmark of 79
10
All Cause Readmission
11
AMI Readmission
12
CABG Readmission
13
HF Readmission
14
COPD Readmission
15
Pneumonia Readmission
16
Solution Approach
Patients are risk stratified per the Modified Lace Tool
Focus is on high risk patients
Disease specific education with daily teach back method
Nursing Home Collaboration for high risk heart failure patients
Transition Care Nurses make visits to local nursing homes
SSM Home Connections visits to nursing homes in rural nursing homes
17
Solution Approach
Pharmacy admission and discharge medication reconciliation and disease specific education
Multi-disciplinary discharge planning on admission
Standing orderset used to place appropriate consults
Daily flash rounds to discuss discharge planning with a multidisciplinary team
18
Solution Approach
Daily meeting with SSM Home Health to review high risk patients
Daily assessment and report potential hazards for readmission to physician
Structured telephone program
Data collection to track leading indicators
Daily readmission report out for the GEMBA program
Weekly readmission RCA
19
Solution Approach
Weekly Core Team Meetings
Implemented on 21517 and ongoing currently
Root cause analysis on each readmission with action planinitiatives reviewedimplemented
Review status on all nursing home patientsvisits and address concerns and identify opportunities
Review at risk patients that are at home and address concerns and identify opportunities
Review leading and lagging indicators and address concerns and identify opportunities
Update on current corrective actions20
Test of ChangeRapid Experiment
Follow up appointment with physician within 5 business days to 100 in 2017
Improve patient actually attending the follow up appointment to 100 in 2017
Home health visits within 24 hours with front loading of visits 100 in 2017
Improve Medication Reconciliation on admission and discharge for all 5 diseases to 100 in 2017
21
Completion Plan
As of June 2017 scales can be provided for low income heart failure patients upon discharge
20172018 Development Projects
Robust palliative care program
Meal delivery program
Rescue Clinic
Improve physician engagement
Enhanced collaboration with LSS and Stonebridge (Quarterly meetings scheduled)
Palliative Care Program (Sub Team developing proposal)
Consider Code HF program (ED Implementation)
22
Confirmed State
Decrease HF readmissions from 202 in 2016 to 153 in 2017
Decrease COPD readmissions 198 in 2016 to 144 in 2017
Decrease PN readmissions from 122 in 2016 to 114 in 2017
Maintain AMI and CABG readmissions at better than the 90th percentile in 2017
23
Questions
24
Readmissions UpdateJosh Grotzinger
25
ICD-10 Readmission Update
October 2015 HIDI developed a GEM-mapped approach to the CMSYale risk-adjusted readmission models to accommodate ICD-9 and ICD-10 codes This action was taken prior to the availability of final ICD-910 compliant models from CMSYale to ensure continuity of readmission reporting for HIDI-participating hospitals
CMSYale released new ICD-910 compliant risk-adjusted readmission models with the release of the 2017 Hospital Compare data
26
CMSYale Documentation
CMSYale have validated their ICD-910 compliant models with documentation on QualityNet
Documentation on additionsexclusions from the cohort definitions are available through CMSYale on QualityNet
HIDI observed very modest levels of variation between the readmission models (HIDI GEM-mapped and CMSYale ICD-910 compliant)
27
Whatrsquos Coming after HIINJessica Stultz
28
Missouri Harm Dashboard
29
Missouri Harm Dashboard
MHA board initiative
Three harms
CAUTI
CLABSI
CDI
Reduce state rate by 10 percent
30
Missouri Harm Dashboard
All Missouri acute care hospitals
Excludes rehab psych LTAC womenrsquos childrens specialty veteransmilitary
Distributed to CEOs quarterly
2017 Q4 dashboard was distributed at district council last week
Targeted education materials to be sent at the leadership level
31
Missouri Harm Dashboard
Includes NHSN data only
Measuring improvement of rates
Most recent SIR will be shown on dashboard
Measuring improvement over state target
Calendar year 2016 baseline
Data will be pulled quarterly
2017 Q4 distributed March 2018
2018 Q1 will be distributed June 2018
32
33
HIIN Regional Boot Camps
To Increase Workersrsquo Safety
34
What to Expect
Attendees will be taught and have the opportunity to demonstrate
De-escalation management
Crisis intervention training to supplement the de-escalation techniques with a focus on mental health populations
Components of rape aggression defense training will be taught to offer realistic self-defense tactics and techniques
35
What to Expect
A holistic approach to reducing both the risk and anxiety surrounding violence in healthcare
Excellent supplement to existing safety programs already in place at your organizations
Offered at no cost to Missouri HRET-HIIN hospitals
Audience
front line staff in all care units (ED critical care and medical-surgical units)
safety and security personnel36
Locations and Times
Workplace safety
Blue Springs
ndash April 11 2018 at the Courtyard Marriott ndash Adams Pointe Conference Center
Springfield
ndash April 25 2018 at the Oasis Hotel and Convention Center
St Charles
ndash May 2 2018 at the Embassy Suites Hotel
Cape Girardeau
ndash May 9 2018 at the Drury Plaza Hotel Conference Center
37
HIIN Project Updates
38
Data Due Dates mdash HIIN Project Year 2
39
MHA ldquoZero Heroesrdquo Club
MHA congratulates the following HIIN-participating hospitals with the most zero harm measures reported These organizations have either achieved andor sustained a zero rate of harm and are in the top 10 percent of HIIN-participating hospitals Congratulations to the ldquoZero Herosrdquo for the month of September
Carroll County Memorial Hospital
Ellett Memorial Hospital
Harrison County Community Hospital
Iron County Medical Center
Osage Beach Center for Cognitive Disorders
Pike County Memorial Hospital
Southeast Health Center of Ripley County
Sullivan County Memorial Hospital
40
AHArsquos IT department investigated the emails and discovered they were generated by groups from Germany and Switzerland AHA recommends that your IT department block emails from these two countries unless you do business with them
SPAM Email from HEN or HIIN Finance mdash PLEASE IGNORE
If you receive an email asking you to pay your invoice via a link please ignore and permanently delete Do not click on the link in the email The email may come from different email addresses but is titled as HENHIIN Finance or HRET HIIN similar to what is pictured below
41
Hospital Leadership and Quality Assessment Tool
The tool measures board members C-suite executives and managementsupervisors on how well they are implementing evidence-based practices shown to support a culture of safety and high performance in clinical quality measures
No front-line staff survey component
Survey content
FAQ
42
HLQAT Survey
MHA is providing this complimentary opportunity for all HIIN hospitals to access and utilize this survey
Two options
Phase I mdash Completed
Phase II mdash April through August 2018
ndash Available to all HIIN hospitals mdash previous participation not
required
ndash Phase I hospitals may participate in phase II if desired
ndash Intent to participate materials will be sent to HIIN contacts soon
43
Qualaris Audit Tool Projects
Hand Hygiene
Culture of Safety Rounding
Sepsis
ReadmissionsCare Transitions
44
Qualaris mdash New Tools
Qualaris has new tools to assist users with coordinating successful improvement projects
Tracking project outcomes alongside process measures
Real-time dashboards inclusive of both outcomes and process measures
Documenting PDSAs
Click here to view the Qualaris improvement projects and outcomes demo
These tools require a short setup webinar session with Qualaris
Readmission Immersion Project participants should contact supportqualariscom
Use the Qualaris virtual chat support for next steps
45
LEAN Six Sigma Green Belt Project
Project launching mdashMarch 13 2018 through November 30 2018
Hospitals committed mdash20
Topic-focused
Patient throughput
ICU harm reduction
Errors in medication reconciliation
46
Capital Region Medical Center
Carroll County Memorial Hospital
Cass Regional Medical Center
Cox Medical Center
Fitzgibbon Hospital
Golden Valley Memorial Healthcare
Hannibal Regional Hospital
Lafayette Regional Health Center
Lake Regional Health System
Liberty Hospital
North Kansas City Hospital
Ozark Medical Center
Perry County Memorial Hospital
Saint Lukes Health System
Saint Lukes Hospital Kansas City
Scotland County Hospital
Southeast Missouri Hospital
St Marys Medical Center
Ste Genevieve County Memorial Hospital
Western Missouri Medical Center
NHSN Reporting Facilities
The January 23rd release of the NHSN 881 application will introduce an updated NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled in NHSN prior to December 2 2017 Facilities that enrolled in NHSN on or after December 2 2017 have already accessed this new Consent and will not need to accept it again if they have already done so
Primary Contacts or Facility Administrators should agree to this updated Consent form for each component by April 14th 2018 or risk losing access to NHSN
An alert will appear on all NHSN component home pages and primary contacts and facility administrators will receive an email notification
Additional information including Frequently Asked Questions and the updated NHSN purposes are available on CDCs NHSN website If you have any questions please send an email to NHSNcdcgov with the subject line ldquoNHSN Reconsentrdquo
47
NHSN Reporting Facilities
The NHSN team has published informational guidance on our website to assist users with completion of the updated NHSN Agreement to Participate and Consent A 5-minute video informs users of the new Consent purposes and the simple process for accepting the Consent electronically Furthermore a step-by-step guidance document provides detailed instructions and screen shots for what Facility Administrators and Primary Contacts can expect to see when they begin the re-consent process in the NHSN application A link to the video and the guidance document can both be found in the FAQs About NHSNrsquos Agreement to Participate and Consent
48
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
SSM Healthrsquos Quality Principles
Patients and other customers are our first priority
Quality is achieved through people
All work is part of a process
Decision-making by facts
Quality requires continuous quality improvement
5
ProblemReason for Action
Overall readmission rate is a component of Value Based Purchasing and is used to determine financial penalties that may or may not occur from CMS
At SSM St Maryrsquos Hospital Jefferson City our objective is to be better than the expected rate of CMS readmissions This would in turn prevent us from receiving a penalty and allow us to obtain dollars that are left on the CMS table while enhancing patient experience and outcomes in high risk patient populations
6
Goal
A goal of 81 has been set for all cause readmissions for our facility
With a focus on AMI (acute myocardial infarction) CABG (coronary artery bypass grafting) HF (heart failure) COPD (chronic obstructive pulmonary disease) and PN (pneumonia) readmissions
7
Future State
Goal is to avoid hospital readmissions and increase our patientrsquos quality of life
Improving patient outcomes is the ultimate goal of hospital quality improvement
Gap Analysis
Current State
Focus on all cause readmissions for high risk patient populations with the following diagnoses
ndash HF
ndash AMI
ndash CABG
ndash COPD
ndash Pneumonia
8
Improving Quality of Care and Reducing Readmissions
Improvement of 3 month rolling heart failure readmission rate from 206 in March 2017 to 14 in July 2017
Improvement of 12 month rolling COPD readmission rate from 183 in August 2016 to 152 in August 2017
Improvement of 3 month rolling COPD readmission rate from 206 in May of 2017 to 47 in August 2017
9
Improving Quality of Care and Reducing Readmissions
Improvement of 12 month rolling pneumonia readmission rate from 133 in May 2016 to 101 in April 2017
Maintained 12 month rolling CABG readmission rate below the premier benchmark of 79
10
All Cause Readmission
11
AMI Readmission
12
CABG Readmission
13
HF Readmission
14
COPD Readmission
15
Pneumonia Readmission
16
Solution Approach
Patients are risk stratified per the Modified Lace Tool
Focus is on high risk patients
Disease specific education with daily teach back method
Nursing Home Collaboration for high risk heart failure patients
Transition Care Nurses make visits to local nursing homes
SSM Home Connections visits to nursing homes in rural nursing homes
17
Solution Approach
Pharmacy admission and discharge medication reconciliation and disease specific education
Multi-disciplinary discharge planning on admission
Standing orderset used to place appropriate consults
Daily flash rounds to discuss discharge planning with a multidisciplinary team
18
Solution Approach
Daily meeting with SSM Home Health to review high risk patients
Daily assessment and report potential hazards for readmission to physician
Structured telephone program
Data collection to track leading indicators
Daily readmission report out for the GEMBA program
Weekly readmission RCA
19
Solution Approach
Weekly Core Team Meetings
Implemented on 21517 and ongoing currently
Root cause analysis on each readmission with action planinitiatives reviewedimplemented
Review status on all nursing home patientsvisits and address concerns and identify opportunities
Review at risk patients that are at home and address concerns and identify opportunities
Review leading and lagging indicators and address concerns and identify opportunities
Update on current corrective actions20
Test of ChangeRapid Experiment
Follow up appointment with physician within 5 business days to 100 in 2017
Improve patient actually attending the follow up appointment to 100 in 2017
Home health visits within 24 hours with front loading of visits 100 in 2017
Improve Medication Reconciliation on admission and discharge for all 5 diseases to 100 in 2017
21
Completion Plan
As of June 2017 scales can be provided for low income heart failure patients upon discharge
20172018 Development Projects
Robust palliative care program
Meal delivery program
Rescue Clinic
Improve physician engagement
Enhanced collaboration with LSS and Stonebridge (Quarterly meetings scheduled)
Palliative Care Program (Sub Team developing proposal)
Consider Code HF program (ED Implementation)
22
Confirmed State
Decrease HF readmissions from 202 in 2016 to 153 in 2017
Decrease COPD readmissions 198 in 2016 to 144 in 2017
Decrease PN readmissions from 122 in 2016 to 114 in 2017
Maintain AMI and CABG readmissions at better than the 90th percentile in 2017
23
Questions
24
Readmissions UpdateJosh Grotzinger
25
ICD-10 Readmission Update
October 2015 HIDI developed a GEM-mapped approach to the CMSYale risk-adjusted readmission models to accommodate ICD-9 and ICD-10 codes This action was taken prior to the availability of final ICD-910 compliant models from CMSYale to ensure continuity of readmission reporting for HIDI-participating hospitals
CMSYale released new ICD-910 compliant risk-adjusted readmission models with the release of the 2017 Hospital Compare data
26
CMSYale Documentation
CMSYale have validated their ICD-910 compliant models with documentation on QualityNet
Documentation on additionsexclusions from the cohort definitions are available through CMSYale on QualityNet
HIDI observed very modest levels of variation between the readmission models (HIDI GEM-mapped and CMSYale ICD-910 compliant)
27
Whatrsquos Coming after HIINJessica Stultz
28
Missouri Harm Dashboard
29
Missouri Harm Dashboard
MHA board initiative
Three harms
CAUTI
CLABSI
CDI
Reduce state rate by 10 percent
30
Missouri Harm Dashboard
All Missouri acute care hospitals
Excludes rehab psych LTAC womenrsquos childrens specialty veteransmilitary
Distributed to CEOs quarterly
2017 Q4 dashboard was distributed at district council last week
Targeted education materials to be sent at the leadership level
31
Missouri Harm Dashboard
Includes NHSN data only
Measuring improvement of rates
Most recent SIR will be shown on dashboard
Measuring improvement over state target
Calendar year 2016 baseline
Data will be pulled quarterly
2017 Q4 distributed March 2018
2018 Q1 will be distributed June 2018
32
33
HIIN Regional Boot Camps
To Increase Workersrsquo Safety
34
What to Expect
Attendees will be taught and have the opportunity to demonstrate
De-escalation management
Crisis intervention training to supplement the de-escalation techniques with a focus on mental health populations
Components of rape aggression defense training will be taught to offer realistic self-defense tactics and techniques
35
What to Expect
A holistic approach to reducing both the risk and anxiety surrounding violence in healthcare
Excellent supplement to existing safety programs already in place at your organizations
Offered at no cost to Missouri HRET-HIIN hospitals
Audience
front line staff in all care units (ED critical care and medical-surgical units)
safety and security personnel36
Locations and Times
Workplace safety
Blue Springs
ndash April 11 2018 at the Courtyard Marriott ndash Adams Pointe Conference Center
Springfield
ndash April 25 2018 at the Oasis Hotel and Convention Center
St Charles
ndash May 2 2018 at the Embassy Suites Hotel
Cape Girardeau
ndash May 9 2018 at the Drury Plaza Hotel Conference Center
37
HIIN Project Updates
38
Data Due Dates mdash HIIN Project Year 2
39
MHA ldquoZero Heroesrdquo Club
MHA congratulates the following HIIN-participating hospitals with the most zero harm measures reported These organizations have either achieved andor sustained a zero rate of harm and are in the top 10 percent of HIIN-participating hospitals Congratulations to the ldquoZero Herosrdquo for the month of September
Carroll County Memorial Hospital
Ellett Memorial Hospital
Harrison County Community Hospital
Iron County Medical Center
Osage Beach Center for Cognitive Disorders
Pike County Memorial Hospital
Southeast Health Center of Ripley County
Sullivan County Memorial Hospital
40
AHArsquos IT department investigated the emails and discovered they were generated by groups from Germany and Switzerland AHA recommends that your IT department block emails from these two countries unless you do business with them
SPAM Email from HEN or HIIN Finance mdash PLEASE IGNORE
If you receive an email asking you to pay your invoice via a link please ignore and permanently delete Do not click on the link in the email The email may come from different email addresses but is titled as HENHIIN Finance or HRET HIIN similar to what is pictured below
41
Hospital Leadership and Quality Assessment Tool
The tool measures board members C-suite executives and managementsupervisors on how well they are implementing evidence-based practices shown to support a culture of safety and high performance in clinical quality measures
No front-line staff survey component
Survey content
FAQ
42
HLQAT Survey
MHA is providing this complimentary opportunity for all HIIN hospitals to access and utilize this survey
Two options
Phase I mdash Completed
Phase II mdash April through August 2018
ndash Available to all HIIN hospitals mdash previous participation not
required
ndash Phase I hospitals may participate in phase II if desired
ndash Intent to participate materials will be sent to HIIN contacts soon
43
Qualaris Audit Tool Projects
Hand Hygiene
Culture of Safety Rounding
Sepsis
ReadmissionsCare Transitions
44
Qualaris mdash New Tools
Qualaris has new tools to assist users with coordinating successful improvement projects
Tracking project outcomes alongside process measures
Real-time dashboards inclusive of both outcomes and process measures
Documenting PDSAs
Click here to view the Qualaris improvement projects and outcomes demo
These tools require a short setup webinar session with Qualaris
Readmission Immersion Project participants should contact supportqualariscom
Use the Qualaris virtual chat support for next steps
45
LEAN Six Sigma Green Belt Project
Project launching mdashMarch 13 2018 through November 30 2018
Hospitals committed mdash20
Topic-focused
Patient throughput
ICU harm reduction
Errors in medication reconciliation
46
Capital Region Medical Center
Carroll County Memorial Hospital
Cass Regional Medical Center
Cox Medical Center
Fitzgibbon Hospital
Golden Valley Memorial Healthcare
Hannibal Regional Hospital
Lafayette Regional Health Center
Lake Regional Health System
Liberty Hospital
North Kansas City Hospital
Ozark Medical Center
Perry County Memorial Hospital
Saint Lukes Health System
Saint Lukes Hospital Kansas City
Scotland County Hospital
Southeast Missouri Hospital
St Marys Medical Center
Ste Genevieve County Memorial Hospital
Western Missouri Medical Center
NHSN Reporting Facilities
The January 23rd release of the NHSN 881 application will introduce an updated NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled in NHSN prior to December 2 2017 Facilities that enrolled in NHSN on or after December 2 2017 have already accessed this new Consent and will not need to accept it again if they have already done so
Primary Contacts or Facility Administrators should agree to this updated Consent form for each component by April 14th 2018 or risk losing access to NHSN
An alert will appear on all NHSN component home pages and primary contacts and facility administrators will receive an email notification
Additional information including Frequently Asked Questions and the updated NHSN purposes are available on CDCs NHSN website If you have any questions please send an email to NHSNcdcgov with the subject line ldquoNHSN Reconsentrdquo
47
NHSN Reporting Facilities
The NHSN team has published informational guidance on our website to assist users with completion of the updated NHSN Agreement to Participate and Consent A 5-minute video informs users of the new Consent purposes and the simple process for accepting the Consent electronically Furthermore a step-by-step guidance document provides detailed instructions and screen shots for what Facility Administrators and Primary Contacts can expect to see when they begin the re-consent process in the NHSN application A link to the video and the guidance document can both be found in the FAQs About NHSNrsquos Agreement to Participate and Consent
48
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
ProblemReason for Action
Overall readmission rate is a component of Value Based Purchasing and is used to determine financial penalties that may or may not occur from CMS
At SSM St Maryrsquos Hospital Jefferson City our objective is to be better than the expected rate of CMS readmissions This would in turn prevent us from receiving a penalty and allow us to obtain dollars that are left on the CMS table while enhancing patient experience and outcomes in high risk patient populations
6
Goal
A goal of 81 has been set for all cause readmissions for our facility
With a focus on AMI (acute myocardial infarction) CABG (coronary artery bypass grafting) HF (heart failure) COPD (chronic obstructive pulmonary disease) and PN (pneumonia) readmissions
7
Future State
Goal is to avoid hospital readmissions and increase our patientrsquos quality of life
Improving patient outcomes is the ultimate goal of hospital quality improvement
Gap Analysis
Current State
Focus on all cause readmissions for high risk patient populations with the following diagnoses
ndash HF
ndash AMI
ndash CABG
ndash COPD
ndash Pneumonia
8
Improving Quality of Care and Reducing Readmissions
Improvement of 3 month rolling heart failure readmission rate from 206 in March 2017 to 14 in July 2017
Improvement of 12 month rolling COPD readmission rate from 183 in August 2016 to 152 in August 2017
Improvement of 3 month rolling COPD readmission rate from 206 in May of 2017 to 47 in August 2017
9
Improving Quality of Care and Reducing Readmissions
Improvement of 12 month rolling pneumonia readmission rate from 133 in May 2016 to 101 in April 2017
Maintained 12 month rolling CABG readmission rate below the premier benchmark of 79
10
All Cause Readmission
11
AMI Readmission
12
CABG Readmission
13
HF Readmission
14
COPD Readmission
15
Pneumonia Readmission
16
Solution Approach
Patients are risk stratified per the Modified Lace Tool
Focus is on high risk patients
Disease specific education with daily teach back method
Nursing Home Collaboration for high risk heart failure patients
Transition Care Nurses make visits to local nursing homes
SSM Home Connections visits to nursing homes in rural nursing homes
17
Solution Approach
Pharmacy admission and discharge medication reconciliation and disease specific education
Multi-disciplinary discharge planning on admission
Standing orderset used to place appropriate consults
Daily flash rounds to discuss discharge planning with a multidisciplinary team
18
Solution Approach
Daily meeting with SSM Home Health to review high risk patients
Daily assessment and report potential hazards for readmission to physician
Structured telephone program
Data collection to track leading indicators
Daily readmission report out for the GEMBA program
Weekly readmission RCA
19
Solution Approach
Weekly Core Team Meetings
Implemented on 21517 and ongoing currently
Root cause analysis on each readmission with action planinitiatives reviewedimplemented
Review status on all nursing home patientsvisits and address concerns and identify opportunities
Review at risk patients that are at home and address concerns and identify opportunities
Review leading and lagging indicators and address concerns and identify opportunities
Update on current corrective actions20
Test of ChangeRapid Experiment
Follow up appointment with physician within 5 business days to 100 in 2017
Improve patient actually attending the follow up appointment to 100 in 2017
Home health visits within 24 hours with front loading of visits 100 in 2017
Improve Medication Reconciliation on admission and discharge for all 5 diseases to 100 in 2017
21
Completion Plan
As of June 2017 scales can be provided for low income heart failure patients upon discharge
20172018 Development Projects
Robust palliative care program
Meal delivery program
Rescue Clinic
Improve physician engagement
Enhanced collaboration with LSS and Stonebridge (Quarterly meetings scheduled)
Palliative Care Program (Sub Team developing proposal)
Consider Code HF program (ED Implementation)
22
Confirmed State
Decrease HF readmissions from 202 in 2016 to 153 in 2017
Decrease COPD readmissions 198 in 2016 to 144 in 2017
Decrease PN readmissions from 122 in 2016 to 114 in 2017
Maintain AMI and CABG readmissions at better than the 90th percentile in 2017
23
Questions
24
Readmissions UpdateJosh Grotzinger
25
ICD-10 Readmission Update
October 2015 HIDI developed a GEM-mapped approach to the CMSYale risk-adjusted readmission models to accommodate ICD-9 and ICD-10 codes This action was taken prior to the availability of final ICD-910 compliant models from CMSYale to ensure continuity of readmission reporting for HIDI-participating hospitals
CMSYale released new ICD-910 compliant risk-adjusted readmission models with the release of the 2017 Hospital Compare data
26
CMSYale Documentation
CMSYale have validated their ICD-910 compliant models with documentation on QualityNet
Documentation on additionsexclusions from the cohort definitions are available through CMSYale on QualityNet
HIDI observed very modest levels of variation between the readmission models (HIDI GEM-mapped and CMSYale ICD-910 compliant)
27
Whatrsquos Coming after HIINJessica Stultz
28
Missouri Harm Dashboard
29
Missouri Harm Dashboard
MHA board initiative
Three harms
CAUTI
CLABSI
CDI
Reduce state rate by 10 percent
30
Missouri Harm Dashboard
All Missouri acute care hospitals
Excludes rehab psych LTAC womenrsquos childrens specialty veteransmilitary
Distributed to CEOs quarterly
2017 Q4 dashboard was distributed at district council last week
Targeted education materials to be sent at the leadership level
31
Missouri Harm Dashboard
Includes NHSN data only
Measuring improvement of rates
Most recent SIR will be shown on dashboard
Measuring improvement over state target
Calendar year 2016 baseline
Data will be pulled quarterly
2017 Q4 distributed March 2018
2018 Q1 will be distributed June 2018
32
33
HIIN Regional Boot Camps
To Increase Workersrsquo Safety
34
What to Expect
Attendees will be taught and have the opportunity to demonstrate
De-escalation management
Crisis intervention training to supplement the de-escalation techniques with a focus on mental health populations
Components of rape aggression defense training will be taught to offer realistic self-defense tactics and techniques
35
What to Expect
A holistic approach to reducing both the risk and anxiety surrounding violence in healthcare
Excellent supplement to existing safety programs already in place at your organizations
Offered at no cost to Missouri HRET-HIIN hospitals
Audience
front line staff in all care units (ED critical care and medical-surgical units)
safety and security personnel36
Locations and Times
Workplace safety
Blue Springs
ndash April 11 2018 at the Courtyard Marriott ndash Adams Pointe Conference Center
Springfield
ndash April 25 2018 at the Oasis Hotel and Convention Center
St Charles
ndash May 2 2018 at the Embassy Suites Hotel
Cape Girardeau
ndash May 9 2018 at the Drury Plaza Hotel Conference Center
37
HIIN Project Updates
38
Data Due Dates mdash HIIN Project Year 2
39
MHA ldquoZero Heroesrdquo Club
MHA congratulates the following HIIN-participating hospitals with the most zero harm measures reported These organizations have either achieved andor sustained a zero rate of harm and are in the top 10 percent of HIIN-participating hospitals Congratulations to the ldquoZero Herosrdquo for the month of September
Carroll County Memorial Hospital
Ellett Memorial Hospital
Harrison County Community Hospital
Iron County Medical Center
Osage Beach Center for Cognitive Disorders
Pike County Memorial Hospital
Southeast Health Center of Ripley County
Sullivan County Memorial Hospital
40
AHArsquos IT department investigated the emails and discovered they were generated by groups from Germany and Switzerland AHA recommends that your IT department block emails from these two countries unless you do business with them
SPAM Email from HEN or HIIN Finance mdash PLEASE IGNORE
If you receive an email asking you to pay your invoice via a link please ignore and permanently delete Do not click on the link in the email The email may come from different email addresses but is titled as HENHIIN Finance or HRET HIIN similar to what is pictured below
41
Hospital Leadership and Quality Assessment Tool
The tool measures board members C-suite executives and managementsupervisors on how well they are implementing evidence-based practices shown to support a culture of safety and high performance in clinical quality measures
No front-line staff survey component
Survey content
FAQ
42
HLQAT Survey
MHA is providing this complimentary opportunity for all HIIN hospitals to access and utilize this survey
Two options
Phase I mdash Completed
Phase II mdash April through August 2018
ndash Available to all HIIN hospitals mdash previous participation not
required
ndash Phase I hospitals may participate in phase II if desired
ndash Intent to participate materials will be sent to HIIN contacts soon
43
Qualaris Audit Tool Projects
Hand Hygiene
Culture of Safety Rounding
Sepsis
ReadmissionsCare Transitions
44
Qualaris mdash New Tools
Qualaris has new tools to assist users with coordinating successful improvement projects
Tracking project outcomes alongside process measures
Real-time dashboards inclusive of both outcomes and process measures
Documenting PDSAs
Click here to view the Qualaris improvement projects and outcomes demo
These tools require a short setup webinar session with Qualaris
Readmission Immersion Project participants should contact supportqualariscom
Use the Qualaris virtual chat support for next steps
45
LEAN Six Sigma Green Belt Project
Project launching mdashMarch 13 2018 through November 30 2018
Hospitals committed mdash20
Topic-focused
Patient throughput
ICU harm reduction
Errors in medication reconciliation
46
Capital Region Medical Center
Carroll County Memorial Hospital
Cass Regional Medical Center
Cox Medical Center
Fitzgibbon Hospital
Golden Valley Memorial Healthcare
Hannibal Regional Hospital
Lafayette Regional Health Center
Lake Regional Health System
Liberty Hospital
North Kansas City Hospital
Ozark Medical Center
Perry County Memorial Hospital
Saint Lukes Health System
Saint Lukes Hospital Kansas City
Scotland County Hospital
Southeast Missouri Hospital
St Marys Medical Center
Ste Genevieve County Memorial Hospital
Western Missouri Medical Center
NHSN Reporting Facilities
The January 23rd release of the NHSN 881 application will introduce an updated NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled in NHSN prior to December 2 2017 Facilities that enrolled in NHSN on or after December 2 2017 have already accessed this new Consent and will not need to accept it again if they have already done so
Primary Contacts or Facility Administrators should agree to this updated Consent form for each component by April 14th 2018 or risk losing access to NHSN
An alert will appear on all NHSN component home pages and primary contacts and facility administrators will receive an email notification
Additional information including Frequently Asked Questions and the updated NHSN purposes are available on CDCs NHSN website If you have any questions please send an email to NHSNcdcgov with the subject line ldquoNHSN Reconsentrdquo
47
NHSN Reporting Facilities
The NHSN team has published informational guidance on our website to assist users with completion of the updated NHSN Agreement to Participate and Consent A 5-minute video informs users of the new Consent purposes and the simple process for accepting the Consent electronically Furthermore a step-by-step guidance document provides detailed instructions and screen shots for what Facility Administrators and Primary Contacts can expect to see when they begin the re-consent process in the NHSN application A link to the video and the guidance document can both be found in the FAQs About NHSNrsquos Agreement to Participate and Consent
48
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
Goal
A goal of 81 has been set for all cause readmissions for our facility
With a focus on AMI (acute myocardial infarction) CABG (coronary artery bypass grafting) HF (heart failure) COPD (chronic obstructive pulmonary disease) and PN (pneumonia) readmissions
7
Future State
Goal is to avoid hospital readmissions and increase our patientrsquos quality of life
Improving patient outcomes is the ultimate goal of hospital quality improvement
Gap Analysis
Current State
Focus on all cause readmissions for high risk patient populations with the following diagnoses
ndash HF
ndash AMI
ndash CABG
ndash COPD
ndash Pneumonia
8
Improving Quality of Care and Reducing Readmissions
Improvement of 3 month rolling heart failure readmission rate from 206 in March 2017 to 14 in July 2017
Improvement of 12 month rolling COPD readmission rate from 183 in August 2016 to 152 in August 2017
Improvement of 3 month rolling COPD readmission rate from 206 in May of 2017 to 47 in August 2017
9
Improving Quality of Care and Reducing Readmissions
Improvement of 12 month rolling pneumonia readmission rate from 133 in May 2016 to 101 in April 2017
Maintained 12 month rolling CABG readmission rate below the premier benchmark of 79
10
All Cause Readmission
11
AMI Readmission
12
CABG Readmission
13
HF Readmission
14
COPD Readmission
15
Pneumonia Readmission
16
Solution Approach
Patients are risk stratified per the Modified Lace Tool
Focus is on high risk patients
Disease specific education with daily teach back method
Nursing Home Collaboration for high risk heart failure patients
Transition Care Nurses make visits to local nursing homes
SSM Home Connections visits to nursing homes in rural nursing homes
17
Solution Approach
Pharmacy admission and discharge medication reconciliation and disease specific education
Multi-disciplinary discharge planning on admission
Standing orderset used to place appropriate consults
Daily flash rounds to discuss discharge planning with a multidisciplinary team
18
Solution Approach
Daily meeting with SSM Home Health to review high risk patients
Daily assessment and report potential hazards for readmission to physician
Structured telephone program
Data collection to track leading indicators
Daily readmission report out for the GEMBA program
Weekly readmission RCA
19
Solution Approach
Weekly Core Team Meetings
Implemented on 21517 and ongoing currently
Root cause analysis on each readmission with action planinitiatives reviewedimplemented
Review status on all nursing home patientsvisits and address concerns and identify opportunities
Review at risk patients that are at home and address concerns and identify opportunities
Review leading and lagging indicators and address concerns and identify opportunities
Update on current corrective actions20
Test of ChangeRapid Experiment
Follow up appointment with physician within 5 business days to 100 in 2017
Improve patient actually attending the follow up appointment to 100 in 2017
Home health visits within 24 hours with front loading of visits 100 in 2017
Improve Medication Reconciliation on admission and discharge for all 5 diseases to 100 in 2017
21
Completion Plan
As of June 2017 scales can be provided for low income heart failure patients upon discharge
20172018 Development Projects
Robust palliative care program
Meal delivery program
Rescue Clinic
Improve physician engagement
Enhanced collaboration with LSS and Stonebridge (Quarterly meetings scheduled)
Palliative Care Program (Sub Team developing proposal)
Consider Code HF program (ED Implementation)
22
Confirmed State
Decrease HF readmissions from 202 in 2016 to 153 in 2017
Decrease COPD readmissions 198 in 2016 to 144 in 2017
Decrease PN readmissions from 122 in 2016 to 114 in 2017
Maintain AMI and CABG readmissions at better than the 90th percentile in 2017
23
Questions
24
Readmissions UpdateJosh Grotzinger
25
ICD-10 Readmission Update
October 2015 HIDI developed a GEM-mapped approach to the CMSYale risk-adjusted readmission models to accommodate ICD-9 and ICD-10 codes This action was taken prior to the availability of final ICD-910 compliant models from CMSYale to ensure continuity of readmission reporting for HIDI-participating hospitals
CMSYale released new ICD-910 compliant risk-adjusted readmission models with the release of the 2017 Hospital Compare data
26
CMSYale Documentation
CMSYale have validated their ICD-910 compliant models with documentation on QualityNet
Documentation on additionsexclusions from the cohort definitions are available through CMSYale on QualityNet
HIDI observed very modest levels of variation between the readmission models (HIDI GEM-mapped and CMSYale ICD-910 compliant)
27
Whatrsquos Coming after HIINJessica Stultz
28
Missouri Harm Dashboard
29
Missouri Harm Dashboard
MHA board initiative
Three harms
CAUTI
CLABSI
CDI
Reduce state rate by 10 percent
30
Missouri Harm Dashboard
All Missouri acute care hospitals
Excludes rehab psych LTAC womenrsquos childrens specialty veteransmilitary
Distributed to CEOs quarterly
2017 Q4 dashboard was distributed at district council last week
Targeted education materials to be sent at the leadership level
31
Missouri Harm Dashboard
Includes NHSN data only
Measuring improvement of rates
Most recent SIR will be shown on dashboard
Measuring improvement over state target
Calendar year 2016 baseline
Data will be pulled quarterly
2017 Q4 distributed March 2018
2018 Q1 will be distributed June 2018
32
33
HIIN Regional Boot Camps
To Increase Workersrsquo Safety
34
What to Expect
Attendees will be taught and have the opportunity to demonstrate
De-escalation management
Crisis intervention training to supplement the de-escalation techniques with a focus on mental health populations
Components of rape aggression defense training will be taught to offer realistic self-defense tactics and techniques
35
What to Expect
A holistic approach to reducing both the risk and anxiety surrounding violence in healthcare
Excellent supplement to existing safety programs already in place at your organizations
Offered at no cost to Missouri HRET-HIIN hospitals
Audience
front line staff in all care units (ED critical care and medical-surgical units)
safety and security personnel36
Locations and Times
Workplace safety
Blue Springs
ndash April 11 2018 at the Courtyard Marriott ndash Adams Pointe Conference Center
Springfield
ndash April 25 2018 at the Oasis Hotel and Convention Center
St Charles
ndash May 2 2018 at the Embassy Suites Hotel
Cape Girardeau
ndash May 9 2018 at the Drury Plaza Hotel Conference Center
37
HIIN Project Updates
38
Data Due Dates mdash HIIN Project Year 2
39
MHA ldquoZero Heroesrdquo Club
MHA congratulates the following HIIN-participating hospitals with the most zero harm measures reported These organizations have either achieved andor sustained a zero rate of harm and are in the top 10 percent of HIIN-participating hospitals Congratulations to the ldquoZero Herosrdquo for the month of September
Carroll County Memorial Hospital
Ellett Memorial Hospital
Harrison County Community Hospital
Iron County Medical Center
Osage Beach Center for Cognitive Disorders
Pike County Memorial Hospital
Southeast Health Center of Ripley County
Sullivan County Memorial Hospital
40
AHArsquos IT department investigated the emails and discovered they were generated by groups from Germany and Switzerland AHA recommends that your IT department block emails from these two countries unless you do business with them
SPAM Email from HEN or HIIN Finance mdash PLEASE IGNORE
If you receive an email asking you to pay your invoice via a link please ignore and permanently delete Do not click on the link in the email The email may come from different email addresses but is titled as HENHIIN Finance or HRET HIIN similar to what is pictured below
41
Hospital Leadership and Quality Assessment Tool
The tool measures board members C-suite executives and managementsupervisors on how well they are implementing evidence-based practices shown to support a culture of safety and high performance in clinical quality measures
No front-line staff survey component
Survey content
FAQ
42
HLQAT Survey
MHA is providing this complimentary opportunity for all HIIN hospitals to access and utilize this survey
Two options
Phase I mdash Completed
Phase II mdash April through August 2018
ndash Available to all HIIN hospitals mdash previous participation not
required
ndash Phase I hospitals may participate in phase II if desired
ndash Intent to participate materials will be sent to HIIN contacts soon
43
Qualaris Audit Tool Projects
Hand Hygiene
Culture of Safety Rounding
Sepsis
ReadmissionsCare Transitions
44
Qualaris mdash New Tools
Qualaris has new tools to assist users with coordinating successful improvement projects
Tracking project outcomes alongside process measures
Real-time dashboards inclusive of both outcomes and process measures
Documenting PDSAs
Click here to view the Qualaris improvement projects and outcomes demo
These tools require a short setup webinar session with Qualaris
Readmission Immersion Project participants should contact supportqualariscom
Use the Qualaris virtual chat support for next steps
45
LEAN Six Sigma Green Belt Project
Project launching mdashMarch 13 2018 through November 30 2018
Hospitals committed mdash20
Topic-focused
Patient throughput
ICU harm reduction
Errors in medication reconciliation
46
Capital Region Medical Center
Carroll County Memorial Hospital
Cass Regional Medical Center
Cox Medical Center
Fitzgibbon Hospital
Golden Valley Memorial Healthcare
Hannibal Regional Hospital
Lafayette Regional Health Center
Lake Regional Health System
Liberty Hospital
North Kansas City Hospital
Ozark Medical Center
Perry County Memorial Hospital
Saint Lukes Health System
Saint Lukes Hospital Kansas City
Scotland County Hospital
Southeast Missouri Hospital
St Marys Medical Center
Ste Genevieve County Memorial Hospital
Western Missouri Medical Center
NHSN Reporting Facilities
The January 23rd release of the NHSN 881 application will introduce an updated NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled in NHSN prior to December 2 2017 Facilities that enrolled in NHSN on or after December 2 2017 have already accessed this new Consent and will not need to accept it again if they have already done so
Primary Contacts or Facility Administrators should agree to this updated Consent form for each component by April 14th 2018 or risk losing access to NHSN
An alert will appear on all NHSN component home pages and primary contacts and facility administrators will receive an email notification
Additional information including Frequently Asked Questions and the updated NHSN purposes are available on CDCs NHSN website If you have any questions please send an email to NHSNcdcgov with the subject line ldquoNHSN Reconsentrdquo
47
NHSN Reporting Facilities
The NHSN team has published informational guidance on our website to assist users with completion of the updated NHSN Agreement to Participate and Consent A 5-minute video informs users of the new Consent purposes and the simple process for accepting the Consent electronically Furthermore a step-by-step guidance document provides detailed instructions and screen shots for what Facility Administrators and Primary Contacts can expect to see when they begin the re-consent process in the NHSN application A link to the video and the guidance document can both be found in the FAQs About NHSNrsquos Agreement to Participate and Consent
48
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
Future State
Goal is to avoid hospital readmissions and increase our patientrsquos quality of life
Improving patient outcomes is the ultimate goal of hospital quality improvement
Gap Analysis
Current State
Focus on all cause readmissions for high risk patient populations with the following diagnoses
ndash HF
ndash AMI
ndash CABG
ndash COPD
ndash Pneumonia
8
Improving Quality of Care and Reducing Readmissions
Improvement of 3 month rolling heart failure readmission rate from 206 in March 2017 to 14 in July 2017
Improvement of 12 month rolling COPD readmission rate from 183 in August 2016 to 152 in August 2017
Improvement of 3 month rolling COPD readmission rate from 206 in May of 2017 to 47 in August 2017
9
Improving Quality of Care and Reducing Readmissions
Improvement of 12 month rolling pneumonia readmission rate from 133 in May 2016 to 101 in April 2017
Maintained 12 month rolling CABG readmission rate below the premier benchmark of 79
10
All Cause Readmission
11
AMI Readmission
12
CABG Readmission
13
HF Readmission
14
COPD Readmission
15
Pneumonia Readmission
16
Solution Approach
Patients are risk stratified per the Modified Lace Tool
Focus is on high risk patients
Disease specific education with daily teach back method
Nursing Home Collaboration for high risk heart failure patients
Transition Care Nurses make visits to local nursing homes
SSM Home Connections visits to nursing homes in rural nursing homes
17
Solution Approach
Pharmacy admission and discharge medication reconciliation and disease specific education
Multi-disciplinary discharge planning on admission
Standing orderset used to place appropriate consults
Daily flash rounds to discuss discharge planning with a multidisciplinary team
18
Solution Approach
Daily meeting with SSM Home Health to review high risk patients
Daily assessment and report potential hazards for readmission to physician
Structured telephone program
Data collection to track leading indicators
Daily readmission report out for the GEMBA program
Weekly readmission RCA
19
Solution Approach
Weekly Core Team Meetings
Implemented on 21517 and ongoing currently
Root cause analysis on each readmission with action planinitiatives reviewedimplemented
Review status on all nursing home patientsvisits and address concerns and identify opportunities
Review at risk patients that are at home and address concerns and identify opportunities
Review leading and lagging indicators and address concerns and identify opportunities
Update on current corrective actions20
Test of ChangeRapid Experiment
Follow up appointment with physician within 5 business days to 100 in 2017
Improve patient actually attending the follow up appointment to 100 in 2017
Home health visits within 24 hours with front loading of visits 100 in 2017
Improve Medication Reconciliation on admission and discharge for all 5 diseases to 100 in 2017
21
Completion Plan
As of June 2017 scales can be provided for low income heart failure patients upon discharge
20172018 Development Projects
Robust palliative care program
Meal delivery program
Rescue Clinic
Improve physician engagement
Enhanced collaboration with LSS and Stonebridge (Quarterly meetings scheduled)
Palliative Care Program (Sub Team developing proposal)
Consider Code HF program (ED Implementation)
22
Confirmed State
Decrease HF readmissions from 202 in 2016 to 153 in 2017
Decrease COPD readmissions 198 in 2016 to 144 in 2017
Decrease PN readmissions from 122 in 2016 to 114 in 2017
Maintain AMI and CABG readmissions at better than the 90th percentile in 2017
23
Questions
24
Readmissions UpdateJosh Grotzinger
25
ICD-10 Readmission Update
October 2015 HIDI developed a GEM-mapped approach to the CMSYale risk-adjusted readmission models to accommodate ICD-9 and ICD-10 codes This action was taken prior to the availability of final ICD-910 compliant models from CMSYale to ensure continuity of readmission reporting for HIDI-participating hospitals
CMSYale released new ICD-910 compliant risk-adjusted readmission models with the release of the 2017 Hospital Compare data
26
CMSYale Documentation
CMSYale have validated their ICD-910 compliant models with documentation on QualityNet
Documentation on additionsexclusions from the cohort definitions are available through CMSYale on QualityNet
HIDI observed very modest levels of variation between the readmission models (HIDI GEM-mapped and CMSYale ICD-910 compliant)
27
Whatrsquos Coming after HIINJessica Stultz
28
Missouri Harm Dashboard
29
Missouri Harm Dashboard
MHA board initiative
Three harms
CAUTI
CLABSI
CDI
Reduce state rate by 10 percent
30
Missouri Harm Dashboard
All Missouri acute care hospitals
Excludes rehab psych LTAC womenrsquos childrens specialty veteransmilitary
Distributed to CEOs quarterly
2017 Q4 dashboard was distributed at district council last week
Targeted education materials to be sent at the leadership level
31
Missouri Harm Dashboard
Includes NHSN data only
Measuring improvement of rates
Most recent SIR will be shown on dashboard
Measuring improvement over state target
Calendar year 2016 baseline
Data will be pulled quarterly
2017 Q4 distributed March 2018
2018 Q1 will be distributed June 2018
32
33
HIIN Regional Boot Camps
To Increase Workersrsquo Safety
34
What to Expect
Attendees will be taught and have the opportunity to demonstrate
De-escalation management
Crisis intervention training to supplement the de-escalation techniques with a focus on mental health populations
Components of rape aggression defense training will be taught to offer realistic self-defense tactics and techniques
35
What to Expect
A holistic approach to reducing both the risk and anxiety surrounding violence in healthcare
Excellent supplement to existing safety programs already in place at your organizations
Offered at no cost to Missouri HRET-HIIN hospitals
Audience
front line staff in all care units (ED critical care and medical-surgical units)
safety and security personnel36
Locations and Times
Workplace safety
Blue Springs
ndash April 11 2018 at the Courtyard Marriott ndash Adams Pointe Conference Center
Springfield
ndash April 25 2018 at the Oasis Hotel and Convention Center
St Charles
ndash May 2 2018 at the Embassy Suites Hotel
Cape Girardeau
ndash May 9 2018 at the Drury Plaza Hotel Conference Center
37
HIIN Project Updates
38
Data Due Dates mdash HIIN Project Year 2
39
MHA ldquoZero Heroesrdquo Club
MHA congratulates the following HIIN-participating hospitals with the most zero harm measures reported These organizations have either achieved andor sustained a zero rate of harm and are in the top 10 percent of HIIN-participating hospitals Congratulations to the ldquoZero Herosrdquo for the month of September
Carroll County Memorial Hospital
Ellett Memorial Hospital
Harrison County Community Hospital
Iron County Medical Center
Osage Beach Center for Cognitive Disorders
Pike County Memorial Hospital
Southeast Health Center of Ripley County
Sullivan County Memorial Hospital
40
AHArsquos IT department investigated the emails and discovered they were generated by groups from Germany and Switzerland AHA recommends that your IT department block emails from these two countries unless you do business with them
SPAM Email from HEN or HIIN Finance mdash PLEASE IGNORE
If you receive an email asking you to pay your invoice via a link please ignore and permanently delete Do not click on the link in the email The email may come from different email addresses but is titled as HENHIIN Finance or HRET HIIN similar to what is pictured below
41
Hospital Leadership and Quality Assessment Tool
The tool measures board members C-suite executives and managementsupervisors on how well they are implementing evidence-based practices shown to support a culture of safety and high performance in clinical quality measures
No front-line staff survey component
Survey content
FAQ
42
HLQAT Survey
MHA is providing this complimentary opportunity for all HIIN hospitals to access and utilize this survey
Two options
Phase I mdash Completed
Phase II mdash April through August 2018
ndash Available to all HIIN hospitals mdash previous participation not
required
ndash Phase I hospitals may participate in phase II if desired
ndash Intent to participate materials will be sent to HIIN contacts soon
43
Qualaris Audit Tool Projects
Hand Hygiene
Culture of Safety Rounding
Sepsis
ReadmissionsCare Transitions
44
Qualaris mdash New Tools
Qualaris has new tools to assist users with coordinating successful improvement projects
Tracking project outcomes alongside process measures
Real-time dashboards inclusive of both outcomes and process measures
Documenting PDSAs
Click here to view the Qualaris improvement projects and outcomes demo
These tools require a short setup webinar session with Qualaris
Readmission Immersion Project participants should contact supportqualariscom
Use the Qualaris virtual chat support for next steps
45
LEAN Six Sigma Green Belt Project
Project launching mdashMarch 13 2018 through November 30 2018
Hospitals committed mdash20
Topic-focused
Patient throughput
ICU harm reduction
Errors in medication reconciliation
46
Capital Region Medical Center
Carroll County Memorial Hospital
Cass Regional Medical Center
Cox Medical Center
Fitzgibbon Hospital
Golden Valley Memorial Healthcare
Hannibal Regional Hospital
Lafayette Regional Health Center
Lake Regional Health System
Liberty Hospital
North Kansas City Hospital
Ozark Medical Center
Perry County Memorial Hospital
Saint Lukes Health System
Saint Lukes Hospital Kansas City
Scotland County Hospital
Southeast Missouri Hospital
St Marys Medical Center
Ste Genevieve County Memorial Hospital
Western Missouri Medical Center
NHSN Reporting Facilities
The January 23rd release of the NHSN 881 application will introduce an updated NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled in NHSN prior to December 2 2017 Facilities that enrolled in NHSN on or after December 2 2017 have already accessed this new Consent and will not need to accept it again if they have already done so
Primary Contacts or Facility Administrators should agree to this updated Consent form for each component by April 14th 2018 or risk losing access to NHSN
An alert will appear on all NHSN component home pages and primary contacts and facility administrators will receive an email notification
Additional information including Frequently Asked Questions and the updated NHSN purposes are available on CDCs NHSN website If you have any questions please send an email to NHSNcdcgov with the subject line ldquoNHSN Reconsentrdquo
47
NHSN Reporting Facilities
The NHSN team has published informational guidance on our website to assist users with completion of the updated NHSN Agreement to Participate and Consent A 5-minute video informs users of the new Consent purposes and the simple process for accepting the Consent electronically Furthermore a step-by-step guidance document provides detailed instructions and screen shots for what Facility Administrators and Primary Contacts can expect to see when they begin the re-consent process in the NHSN application A link to the video and the guidance document can both be found in the FAQs About NHSNrsquos Agreement to Participate and Consent
48
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
Improving Quality of Care and Reducing Readmissions
Improvement of 3 month rolling heart failure readmission rate from 206 in March 2017 to 14 in July 2017
Improvement of 12 month rolling COPD readmission rate from 183 in August 2016 to 152 in August 2017
Improvement of 3 month rolling COPD readmission rate from 206 in May of 2017 to 47 in August 2017
9
Improving Quality of Care and Reducing Readmissions
Improvement of 12 month rolling pneumonia readmission rate from 133 in May 2016 to 101 in April 2017
Maintained 12 month rolling CABG readmission rate below the premier benchmark of 79
10
All Cause Readmission
11
AMI Readmission
12
CABG Readmission
13
HF Readmission
14
COPD Readmission
15
Pneumonia Readmission
16
Solution Approach
Patients are risk stratified per the Modified Lace Tool
Focus is on high risk patients
Disease specific education with daily teach back method
Nursing Home Collaboration for high risk heart failure patients
Transition Care Nurses make visits to local nursing homes
SSM Home Connections visits to nursing homes in rural nursing homes
17
Solution Approach
Pharmacy admission and discharge medication reconciliation and disease specific education
Multi-disciplinary discharge planning on admission
Standing orderset used to place appropriate consults
Daily flash rounds to discuss discharge planning with a multidisciplinary team
18
Solution Approach
Daily meeting with SSM Home Health to review high risk patients
Daily assessment and report potential hazards for readmission to physician
Structured telephone program
Data collection to track leading indicators
Daily readmission report out for the GEMBA program
Weekly readmission RCA
19
Solution Approach
Weekly Core Team Meetings
Implemented on 21517 and ongoing currently
Root cause analysis on each readmission with action planinitiatives reviewedimplemented
Review status on all nursing home patientsvisits and address concerns and identify opportunities
Review at risk patients that are at home and address concerns and identify opportunities
Review leading and lagging indicators and address concerns and identify opportunities
Update on current corrective actions20
Test of ChangeRapid Experiment
Follow up appointment with physician within 5 business days to 100 in 2017
Improve patient actually attending the follow up appointment to 100 in 2017
Home health visits within 24 hours with front loading of visits 100 in 2017
Improve Medication Reconciliation on admission and discharge for all 5 diseases to 100 in 2017
21
Completion Plan
As of June 2017 scales can be provided for low income heart failure patients upon discharge
20172018 Development Projects
Robust palliative care program
Meal delivery program
Rescue Clinic
Improve physician engagement
Enhanced collaboration with LSS and Stonebridge (Quarterly meetings scheduled)
Palliative Care Program (Sub Team developing proposal)
Consider Code HF program (ED Implementation)
22
Confirmed State
Decrease HF readmissions from 202 in 2016 to 153 in 2017
Decrease COPD readmissions 198 in 2016 to 144 in 2017
Decrease PN readmissions from 122 in 2016 to 114 in 2017
Maintain AMI and CABG readmissions at better than the 90th percentile in 2017
23
Questions
24
Readmissions UpdateJosh Grotzinger
25
ICD-10 Readmission Update
October 2015 HIDI developed a GEM-mapped approach to the CMSYale risk-adjusted readmission models to accommodate ICD-9 and ICD-10 codes This action was taken prior to the availability of final ICD-910 compliant models from CMSYale to ensure continuity of readmission reporting for HIDI-participating hospitals
CMSYale released new ICD-910 compliant risk-adjusted readmission models with the release of the 2017 Hospital Compare data
26
CMSYale Documentation
CMSYale have validated their ICD-910 compliant models with documentation on QualityNet
Documentation on additionsexclusions from the cohort definitions are available through CMSYale on QualityNet
HIDI observed very modest levels of variation between the readmission models (HIDI GEM-mapped and CMSYale ICD-910 compliant)
27
Whatrsquos Coming after HIINJessica Stultz
28
Missouri Harm Dashboard
29
Missouri Harm Dashboard
MHA board initiative
Three harms
CAUTI
CLABSI
CDI
Reduce state rate by 10 percent
30
Missouri Harm Dashboard
All Missouri acute care hospitals
Excludes rehab psych LTAC womenrsquos childrens specialty veteransmilitary
Distributed to CEOs quarterly
2017 Q4 dashboard was distributed at district council last week
Targeted education materials to be sent at the leadership level
31
Missouri Harm Dashboard
Includes NHSN data only
Measuring improvement of rates
Most recent SIR will be shown on dashboard
Measuring improvement over state target
Calendar year 2016 baseline
Data will be pulled quarterly
2017 Q4 distributed March 2018
2018 Q1 will be distributed June 2018
32
33
HIIN Regional Boot Camps
To Increase Workersrsquo Safety
34
What to Expect
Attendees will be taught and have the opportunity to demonstrate
De-escalation management
Crisis intervention training to supplement the de-escalation techniques with a focus on mental health populations
Components of rape aggression defense training will be taught to offer realistic self-defense tactics and techniques
35
What to Expect
A holistic approach to reducing both the risk and anxiety surrounding violence in healthcare
Excellent supplement to existing safety programs already in place at your organizations
Offered at no cost to Missouri HRET-HIIN hospitals
Audience
front line staff in all care units (ED critical care and medical-surgical units)
safety and security personnel36
Locations and Times
Workplace safety
Blue Springs
ndash April 11 2018 at the Courtyard Marriott ndash Adams Pointe Conference Center
Springfield
ndash April 25 2018 at the Oasis Hotel and Convention Center
St Charles
ndash May 2 2018 at the Embassy Suites Hotel
Cape Girardeau
ndash May 9 2018 at the Drury Plaza Hotel Conference Center
37
HIIN Project Updates
38
Data Due Dates mdash HIIN Project Year 2
39
MHA ldquoZero Heroesrdquo Club
MHA congratulates the following HIIN-participating hospitals with the most zero harm measures reported These organizations have either achieved andor sustained a zero rate of harm and are in the top 10 percent of HIIN-participating hospitals Congratulations to the ldquoZero Herosrdquo for the month of September
Carroll County Memorial Hospital
Ellett Memorial Hospital
Harrison County Community Hospital
Iron County Medical Center
Osage Beach Center for Cognitive Disorders
Pike County Memorial Hospital
Southeast Health Center of Ripley County
Sullivan County Memorial Hospital
40
AHArsquos IT department investigated the emails and discovered they were generated by groups from Germany and Switzerland AHA recommends that your IT department block emails from these two countries unless you do business with them
SPAM Email from HEN or HIIN Finance mdash PLEASE IGNORE
If you receive an email asking you to pay your invoice via a link please ignore and permanently delete Do not click on the link in the email The email may come from different email addresses but is titled as HENHIIN Finance or HRET HIIN similar to what is pictured below
41
Hospital Leadership and Quality Assessment Tool
The tool measures board members C-suite executives and managementsupervisors on how well they are implementing evidence-based practices shown to support a culture of safety and high performance in clinical quality measures
No front-line staff survey component
Survey content
FAQ
42
HLQAT Survey
MHA is providing this complimentary opportunity for all HIIN hospitals to access and utilize this survey
Two options
Phase I mdash Completed
Phase II mdash April through August 2018
ndash Available to all HIIN hospitals mdash previous participation not
required
ndash Phase I hospitals may participate in phase II if desired
ndash Intent to participate materials will be sent to HIIN contacts soon
43
Qualaris Audit Tool Projects
Hand Hygiene
Culture of Safety Rounding
Sepsis
ReadmissionsCare Transitions
44
Qualaris mdash New Tools
Qualaris has new tools to assist users with coordinating successful improvement projects
Tracking project outcomes alongside process measures
Real-time dashboards inclusive of both outcomes and process measures
Documenting PDSAs
Click here to view the Qualaris improvement projects and outcomes demo
These tools require a short setup webinar session with Qualaris
Readmission Immersion Project participants should contact supportqualariscom
Use the Qualaris virtual chat support for next steps
45
LEAN Six Sigma Green Belt Project
Project launching mdashMarch 13 2018 through November 30 2018
Hospitals committed mdash20
Topic-focused
Patient throughput
ICU harm reduction
Errors in medication reconciliation
46
Capital Region Medical Center
Carroll County Memorial Hospital
Cass Regional Medical Center
Cox Medical Center
Fitzgibbon Hospital
Golden Valley Memorial Healthcare
Hannibal Regional Hospital
Lafayette Regional Health Center
Lake Regional Health System
Liberty Hospital
North Kansas City Hospital
Ozark Medical Center
Perry County Memorial Hospital
Saint Lukes Health System
Saint Lukes Hospital Kansas City
Scotland County Hospital
Southeast Missouri Hospital
St Marys Medical Center
Ste Genevieve County Memorial Hospital
Western Missouri Medical Center
NHSN Reporting Facilities
The January 23rd release of the NHSN 881 application will introduce an updated NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled in NHSN prior to December 2 2017 Facilities that enrolled in NHSN on or after December 2 2017 have already accessed this new Consent and will not need to accept it again if they have already done so
Primary Contacts or Facility Administrators should agree to this updated Consent form for each component by April 14th 2018 or risk losing access to NHSN
An alert will appear on all NHSN component home pages and primary contacts and facility administrators will receive an email notification
Additional information including Frequently Asked Questions and the updated NHSN purposes are available on CDCs NHSN website If you have any questions please send an email to NHSNcdcgov with the subject line ldquoNHSN Reconsentrdquo
47
NHSN Reporting Facilities
The NHSN team has published informational guidance on our website to assist users with completion of the updated NHSN Agreement to Participate and Consent A 5-minute video informs users of the new Consent purposes and the simple process for accepting the Consent electronically Furthermore a step-by-step guidance document provides detailed instructions and screen shots for what Facility Administrators and Primary Contacts can expect to see when they begin the re-consent process in the NHSN application A link to the video and the guidance document can both be found in the FAQs About NHSNrsquos Agreement to Participate and Consent
48
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
Improving Quality of Care and Reducing Readmissions
Improvement of 12 month rolling pneumonia readmission rate from 133 in May 2016 to 101 in April 2017
Maintained 12 month rolling CABG readmission rate below the premier benchmark of 79
10
All Cause Readmission
11
AMI Readmission
12
CABG Readmission
13
HF Readmission
14
COPD Readmission
15
Pneumonia Readmission
16
Solution Approach
Patients are risk stratified per the Modified Lace Tool
Focus is on high risk patients
Disease specific education with daily teach back method
Nursing Home Collaboration for high risk heart failure patients
Transition Care Nurses make visits to local nursing homes
SSM Home Connections visits to nursing homes in rural nursing homes
17
Solution Approach
Pharmacy admission and discharge medication reconciliation and disease specific education
Multi-disciplinary discharge planning on admission
Standing orderset used to place appropriate consults
Daily flash rounds to discuss discharge planning with a multidisciplinary team
18
Solution Approach
Daily meeting with SSM Home Health to review high risk patients
Daily assessment and report potential hazards for readmission to physician
Structured telephone program
Data collection to track leading indicators
Daily readmission report out for the GEMBA program
Weekly readmission RCA
19
Solution Approach
Weekly Core Team Meetings
Implemented on 21517 and ongoing currently
Root cause analysis on each readmission with action planinitiatives reviewedimplemented
Review status on all nursing home patientsvisits and address concerns and identify opportunities
Review at risk patients that are at home and address concerns and identify opportunities
Review leading and lagging indicators and address concerns and identify opportunities
Update on current corrective actions20
Test of ChangeRapid Experiment
Follow up appointment with physician within 5 business days to 100 in 2017
Improve patient actually attending the follow up appointment to 100 in 2017
Home health visits within 24 hours with front loading of visits 100 in 2017
Improve Medication Reconciliation on admission and discharge for all 5 diseases to 100 in 2017
21
Completion Plan
As of June 2017 scales can be provided for low income heart failure patients upon discharge
20172018 Development Projects
Robust palliative care program
Meal delivery program
Rescue Clinic
Improve physician engagement
Enhanced collaboration with LSS and Stonebridge (Quarterly meetings scheduled)
Palliative Care Program (Sub Team developing proposal)
Consider Code HF program (ED Implementation)
22
Confirmed State
Decrease HF readmissions from 202 in 2016 to 153 in 2017
Decrease COPD readmissions 198 in 2016 to 144 in 2017
Decrease PN readmissions from 122 in 2016 to 114 in 2017
Maintain AMI and CABG readmissions at better than the 90th percentile in 2017
23
Questions
24
Readmissions UpdateJosh Grotzinger
25
ICD-10 Readmission Update
October 2015 HIDI developed a GEM-mapped approach to the CMSYale risk-adjusted readmission models to accommodate ICD-9 and ICD-10 codes This action was taken prior to the availability of final ICD-910 compliant models from CMSYale to ensure continuity of readmission reporting for HIDI-participating hospitals
CMSYale released new ICD-910 compliant risk-adjusted readmission models with the release of the 2017 Hospital Compare data
26
CMSYale Documentation
CMSYale have validated their ICD-910 compliant models with documentation on QualityNet
Documentation on additionsexclusions from the cohort definitions are available through CMSYale on QualityNet
HIDI observed very modest levels of variation between the readmission models (HIDI GEM-mapped and CMSYale ICD-910 compliant)
27
Whatrsquos Coming after HIINJessica Stultz
28
Missouri Harm Dashboard
29
Missouri Harm Dashboard
MHA board initiative
Three harms
CAUTI
CLABSI
CDI
Reduce state rate by 10 percent
30
Missouri Harm Dashboard
All Missouri acute care hospitals
Excludes rehab psych LTAC womenrsquos childrens specialty veteransmilitary
Distributed to CEOs quarterly
2017 Q4 dashboard was distributed at district council last week
Targeted education materials to be sent at the leadership level
31
Missouri Harm Dashboard
Includes NHSN data only
Measuring improvement of rates
Most recent SIR will be shown on dashboard
Measuring improvement over state target
Calendar year 2016 baseline
Data will be pulled quarterly
2017 Q4 distributed March 2018
2018 Q1 will be distributed June 2018
32
33
HIIN Regional Boot Camps
To Increase Workersrsquo Safety
34
What to Expect
Attendees will be taught and have the opportunity to demonstrate
De-escalation management
Crisis intervention training to supplement the de-escalation techniques with a focus on mental health populations
Components of rape aggression defense training will be taught to offer realistic self-defense tactics and techniques
35
What to Expect
A holistic approach to reducing both the risk and anxiety surrounding violence in healthcare
Excellent supplement to existing safety programs already in place at your organizations
Offered at no cost to Missouri HRET-HIIN hospitals
Audience
front line staff in all care units (ED critical care and medical-surgical units)
safety and security personnel36
Locations and Times
Workplace safety
Blue Springs
ndash April 11 2018 at the Courtyard Marriott ndash Adams Pointe Conference Center
Springfield
ndash April 25 2018 at the Oasis Hotel and Convention Center
St Charles
ndash May 2 2018 at the Embassy Suites Hotel
Cape Girardeau
ndash May 9 2018 at the Drury Plaza Hotel Conference Center
37
HIIN Project Updates
38
Data Due Dates mdash HIIN Project Year 2
39
MHA ldquoZero Heroesrdquo Club
MHA congratulates the following HIIN-participating hospitals with the most zero harm measures reported These organizations have either achieved andor sustained a zero rate of harm and are in the top 10 percent of HIIN-participating hospitals Congratulations to the ldquoZero Herosrdquo for the month of September
Carroll County Memorial Hospital
Ellett Memorial Hospital
Harrison County Community Hospital
Iron County Medical Center
Osage Beach Center for Cognitive Disorders
Pike County Memorial Hospital
Southeast Health Center of Ripley County
Sullivan County Memorial Hospital
40
AHArsquos IT department investigated the emails and discovered they were generated by groups from Germany and Switzerland AHA recommends that your IT department block emails from these two countries unless you do business with them
SPAM Email from HEN or HIIN Finance mdash PLEASE IGNORE
If you receive an email asking you to pay your invoice via a link please ignore and permanently delete Do not click on the link in the email The email may come from different email addresses but is titled as HENHIIN Finance or HRET HIIN similar to what is pictured below
41
Hospital Leadership and Quality Assessment Tool
The tool measures board members C-suite executives and managementsupervisors on how well they are implementing evidence-based practices shown to support a culture of safety and high performance in clinical quality measures
No front-line staff survey component
Survey content
FAQ
42
HLQAT Survey
MHA is providing this complimentary opportunity for all HIIN hospitals to access and utilize this survey
Two options
Phase I mdash Completed
Phase II mdash April through August 2018
ndash Available to all HIIN hospitals mdash previous participation not
required
ndash Phase I hospitals may participate in phase II if desired
ndash Intent to participate materials will be sent to HIIN contacts soon
43
Qualaris Audit Tool Projects
Hand Hygiene
Culture of Safety Rounding
Sepsis
ReadmissionsCare Transitions
44
Qualaris mdash New Tools
Qualaris has new tools to assist users with coordinating successful improvement projects
Tracking project outcomes alongside process measures
Real-time dashboards inclusive of both outcomes and process measures
Documenting PDSAs
Click here to view the Qualaris improvement projects and outcomes demo
These tools require a short setup webinar session with Qualaris
Readmission Immersion Project participants should contact supportqualariscom
Use the Qualaris virtual chat support for next steps
45
LEAN Six Sigma Green Belt Project
Project launching mdashMarch 13 2018 through November 30 2018
Hospitals committed mdash20
Topic-focused
Patient throughput
ICU harm reduction
Errors in medication reconciliation
46
Capital Region Medical Center
Carroll County Memorial Hospital
Cass Regional Medical Center
Cox Medical Center
Fitzgibbon Hospital
Golden Valley Memorial Healthcare
Hannibal Regional Hospital
Lafayette Regional Health Center
Lake Regional Health System
Liberty Hospital
North Kansas City Hospital
Ozark Medical Center
Perry County Memorial Hospital
Saint Lukes Health System
Saint Lukes Hospital Kansas City
Scotland County Hospital
Southeast Missouri Hospital
St Marys Medical Center
Ste Genevieve County Memorial Hospital
Western Missouri Medical Center
NHSN Reporting Facilities
The January 23rd release of the NHSN 881 application will introduce an updated NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled in NHSN prior to December 2 2017 Facilities that enrolled in NHSN on or after December 2 2017 have already accessed this new Consent and will not need to accept it again if they have already done so
Primary Contacts or Facility Administrators should agree to this updated Consent form for each component by April 14th 2018 or risk losing access to NHSN
An alert will appear on all NHSN component home pages and primary contacts and facility administrators will receive an email notification
Additional information including Frequently Asked Questions and the updated NHSN purposes are available on CDCs NHSN website If you have any questions please send an email to NHSNcdcgov with the subject line ldquoNHSN Reconsentrdquo
47
NHSN Reporting Facilities
The NHSN team has published informational guidance on our website to assist users with completion of the updated NHSN Agreement to Participate and Consent A 5-minute video informs users of the new Consent purposes and the simple process for accepting the Consent electronically Furthermore a step-by-step guidance document provides detailed instructions and screen shots for what Facility Administrators and Primary Contacts can expect to see when they begin the re-consent process in the NHSN application A link to the video and the guidance document can both be found in the FAQs About NHSNrsquos Agreement to Participate and Consent
48
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
All Cause Readmission
11
AMI Readmission
12
CABG Readmission
13
HF Readmission
14
COPD Readmission
15
Pneumonia Readmission
16
Solution Approach
Patients are risk stratified per the Modified Lace Tool
Focus is on high risk patients
Disease specific education with daily teach back method
Nursing Home Collaboration for high risk heart failure patients
Transition Care Nurses make visits to local nursing homes
SSM Home Connections visits to nursing homes in rural nursing homes
17
Solution Approach
Pharmacy admission and discharge medication reconciliation and disease specific education
Multi-disciplinary discharge planning on admission
Standing orderset used to place appropriate consults
Daily flash rounds to discuss discharge planning with a multidisciplinary team
18
Solution Approach
Daily meeting with SSM Home Health to review high risk patients
Daily assessment and report potential hazards for readmission to physician
Structured telephone program
Data collection to track leading indicators
Daily readmission report out for the GEMBA program
Weekly readmission RCA
19
Solution Approach
Weekly Core Team Meetings
Implemented on 21517 and ongoing currently
Root cause analysis on each readmission with action planinitiatives reviewedimplemented
Review status on all nursing home patientsvisits and address concerns and identify opportunities
Review at risk patients that are at home and address concerns and identify opportunities
Review leading and lagging indicators and address concerns and identify opportunities
Update on current corrective actions20
Test of ChangeRapid Experiment
Follow up appointment with physician within 5 business days to 100 in 2017
Improve patient actually attending the follow up appointment to 100 in 2017
Home health visits within 24 hours with front loading of visits 100 in 2017
Improve Medication Reconciliation on admission and discharge for all 5 diseases to 100 in 2017
21
Completion Plan
As of June 2017 scales can be provided for low income heart failure patients upon discharge
20172018 Development Projects
Robust palliative care program
Meal delivery program
Rescue Clinic
Improve physician engagement
Enhanced collaboration with LSS and Stonebridge (Quarterly meetings scheduled)
Palliative Care Program (Sub Team developing proposal)
Consider Code HF program (ED Implementation)
22
Confirmed State
Decrease HF readmissions from 202 in 2016 to 153 in 2017
Decrease COPD readmissions 198 in 2016 to 144 in 2017
Decrease PN readmissions from 122 in 2016 to 114 in 2017
Maintain AMI and CABG readmissions at better than the 90th percentile in 2017
23
Questions
24
Readmissions UpdateJosh Grotzinger
25
ICD-10 Readmission Update
October 2015 HIDI developed a GEM-mapped approach to the CMSYale risk-adjusted readmission models to accommodate ICD-9 and ICD-10 codes This action was taken prior to the availability of final ICD-910 compliant models from CMSYale to ensure continuity of readmission reporting for HIDI-participating hospitals
CMSYale released new ICD-910 compliant risk-adjusted readmission models with the release of the 2017 Hospital Compare data
26
CMSYale Documentation
CMSYale have validated their ICD-910 compliant models with documentation on QualityNet
Documentation on additionsexclusions from the cohort definitions are available through CMSYale on QualityNet
HIDI observed very modest levels of variation between the readmission models (HIDI GEM-mapped and CMSYale ICD-910 compliant)
27
Whatrsquos Coming after HIINJessica Stultz
28
Missouri Harm Dashboard
29
Missouri Harm Dashboard
MHA board initiative
Three harms
CAUTI
CLABSI
CDI
Reduce state rate by 10 percent
30
Missouri Harm Dashboard
All Missouri acute care hospitals
Excludes rehab psych LTAC womenrsquos childrens specialty veteransmilitary
Distributed to CEOs quarterly
2017 Q4 dashboard was distributed at district council last week
Targeted education materials to be sent at the leadership level
31
Missouri Harm Dashboard
Includes NHSN data only
Measuring improvement of rates
Most recent SIR will be shown on dashboard
Measuring improvement over state target
Calendar year 2016 baseline
Data will be pulled quarterly
2017 Q4 distributed March 2018
2018 Q1 will be distributed June 2018
32
33
HIIN Regional Boot Camps
To Increase Workersrsquo Safety
34
What to Expect
Attendees will be taught and have the opportunity to demonstrate
De-escalation management
Crisis intervention training to supplement the de-escalation techniques with a focus on mental health populations
Components of rape aggression defense training will be taught to offer realistic self-defense tactics and techniques
35
What to Expect
A holistic approach to reducing both the risk and anxiety surrounding violence in healthcare
Excellent supplement to existing safety programs already in place at your organizations
Offered at no cost to Missouri HRET-HIIN hospitals
Audience
front line staff in all care units (ED critical care and medical-surgical units)
safety and security personnel36
Locations and Times
Workplace safety
Blue Springs
ndash April 11 2018 at the Courtyard Marriott ndash Adams Pointe Conference Center
Springfield
ndash April 25 2018 at the Oasis Hotel and Convention Center
St Charles
ndash May 2 2018 at the Embassy Suites Hotel
Cape Girardeau
ndash May 9 2018 at the Drury Plaza Hotel Conference Center
37
HIIN Project Updates
38
Data Due Dates mdash HIIN Project Year 2
39
MHA ldquoZero Heroesrdquo Club
MHA congratulates the following HIIN-participating hospitals with the most zero harm measures reported These organizations have either achieved andor sustained a zero rate of harm and are in the top 10 percent of HIIN-participating hospitals Congratulations to the ldquoZero Herosrdquo for the month of September
Carroll County Memorial Hospital
Ellett Memorial Hospital
Harrison County Community Hospital
Iron County Medical Center
Osage Beach Center for Cognitive Disorders
Pike County Memorial Hospital
Southeast Health Center of Ripley County
Sullivan County Memorial Hospital
40
AHArsquos IT department investigated the emails and discovered they were generated by groups from Germany and Switzerland AHA recommends that your IT department block emails from these two countries unless you do business with them
SPAM Email from HEN or HIIN Finance mdash PLEASE IGNORE
If you receive an email asking you to pay your invoice via a link please ignore and permanently delete Do not click on the link in the email The email may come from different email addresses but is titled as HENHIIN Finance or HRET HIIN similar to what is pictured below
41
Hospital Leadership and Quality Assessment Tool
The tool measures board members C-suite executives and managementsupervisors on how well they are implementing evidence-based practices shown to support a culture of safety and high performance in clinical quality measures
No front-line staff survey component
Survey content
FAQ
42
HLQAT Survey
MHA is providing this complimentary opportunity for all HIIN hospitals to access and utilize this survey
Two options
Phase I mdash Completed
Phase II mdash April through August 2018
ndash Available to all HIIN hospitals mdash previous participation not
required
ndash Phase I hospitals may participate in phase II if desired
ndash Intent to participate materials will be sent to HIIN contacts soon
43
Qualaris Audit Tool Projects
Hand Hygiene
Culture of Safety Rounding
Sepsis
ReadmissionsCare Transitions
44
Qualaris mdash New Tools
Qualaris has new tools to assist users with coordinating successful improvement projects
Tracking project outcomes alongside process measures
Real-time dashboards inclusive of both outcomes and process measures
Documenting PDSAs
Click here to view the Qualaris improvement projects and outcomes demo
These tools require a short setup webinar session with Qualaris
Readmission Immersion Project participants should contact supportqualariscom
Use the Qualaris virtual chat support for next steps
45
LEAN Six Sigma Green Belt Project
Project launching mdashMarch 13 2018 through November 30 2018
Hospitals committed mdash20
Topic-focused
Patient throughput
ICU harm reduction
Errors in medication reconciliation
46
Capital Region Medical Center
Carroll County Memorial Hospital
Cass Regional Medical Center
Cox Medical Center
Fitzgibbon Hospital
Golden Valley Memorial Healthcare
Hannibal Regional Hospital
Lafayette Regional Health Center
Lake Regional Health System
Liberty Hospital
North Kansas City Hospital
Ozark Medical Center
Perry County Memorial Hospital
Saint Lukes Health System
Saint Lukes Hospital Kansas City
Scotland County Hospital
Southeast Missouri Hospital
St Marys Medical Center
Ste Genevieve County Memorial Hospital
Western Missouri Medical Center
NHSN Reporting Facilities
The January 23rd release of the NHSN 881 application will introduce an updated NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled in NHSN prior to December 2 2017 Facilities that enrolled in NHSN on or after December 2 2017 have already accessed this new Consent and will not need to accept it again if they have already done so
Primary Contacts or Facility Administrators should agree to this updated Consent form for each component by April 14th 2018 or risk losing access to NHSN
An alert will appear on all NHSN component home pages and primary contacts and facility administrators will receive an email notification
Additional information including Frequently Asked Questions and the updated NHSN purposes are available on CDCs NHSN website If you have any questions please send an email to NHSNcdcgov with the subject line ldquoNHSN Reconsentrdquo
47
NHSN Reporting Facilities
The NHSN team has published informational guidance on our website to assist users with completion of the updated NHSN Agreement to Participate and Consent A 5-minute video informs users of the new Consent purposes and the simple process for accepting the Consent electronically Furthermore a step-by-step guidance document provides detailed instructions and screen shots for what Facility Administrators and Primary Contacts can expect to see when they begin the re-consent process in the NHSN application A link to the video and the guidance document can both be found in the FAQs About NHSNrsquos Agreement to Participate and Consent
48
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
AMI Readmission
12
CABG Readmission
13
HF Readmission
14
COPD Readmission
15
Pneumonia Readmission
16
Solution Approach
Patients are risk stratified per the Modified Lace Tool
Focus is on high risk patients
Disease specific education with daily teach back method
Nursing Home Collaboration for high risk heart failure patients
Transition Care Nurses make visits to local nursing homes
SSM Home Connections visits to nursing homes in rural nursing homes
17
Solution Approach
Pharmacy admission and discharge medication reconciliation and disease specific education
Multi-disciplinary discharge planning on admission
Standing orderset used to place appropriate consults
Daily flash rounds to discuss discharge planning with a multidisciplinary team
18
Solution Approach
Daily meeting with SSM Home Health to review high risk patients
Daily assessment and report potential hazards for readmission to physician
Structured telephone program
Data collection to track leading indicators
Daily readmission report out for the GEMBA program
Weekly readmission RCA
19
Solution Approach
Weekly Core Team Meetings
Implemented on 21517 and ongoing currently
Root cause analysis on each readmission with action planinitiatives reviewedimplemented
Review status on all nursing home patientsvisits and address concerns and identify opportunities
Review at risk patients that are at home and address concerns and identify opportunities
Review leading and lagging indicators and address concerns and identify opportunities
Update on current corrective actions20
Test of ChangeRapid Experiment
Follow up appointment with physician within 5 business days to 100 in 2017
Improve patient actually attending the follow up appointment to 100 in 2017
Home health visits within 24 hours with front loading of visits 100 in 2017
Improve Medication Reconciliation on admission and discharge for all 5 diseases to 100 in 2017
21
Completion Plan
As of June 2017 scales can be provided for low income heart failure patients upon discharge
20172018 Development Projects
Robust palliative care program
Meal delivery program
Rescue Clinic
Improve physician engagement
Enhanced collaboration with LSS and Stonebridge (Quarterly meetings scheduled)
Palliative Care Program (Sub Team developing proposal)
Consider Code HF program (ED Implementation)
22
Confirmed State
Decrease HF readmissions from 202 in 2016 to 153 in 2017
Decrease COPD readmissions 198 in 2016 to 144 in 2017
Decrease PN readmissions from 122 in 2016 to 114 in 2017
Maintain AMI and CABG readmissions at better than the 90th percentile in 2017
23
Questions
24
Readmissions UpdateJosh Grotzinger
25
ICD-10 Readmission Update
October 2015 HIDI developed a GEM-mapped approach to the CMSYale risk-adjusted readmission models to accommodate ICD-9 and ICD-10 codes This action was taken prior to the availability of final ICD-910 compliant models from CMSYale to ensure continuity of readmission reporting for HIDI-participating hospitals
CMSYale released new ICD-910 compliant risk-adjusted readmission models with the release of the 2017 Hospital Compare data
26
CMSYale Documentation
CMSYale have validated their ICD-910 compliant models with documentation on QualityNet
Documentation on additionsexclusions from the cohort definitions are available through CMSYale on QualityNet
HIDI observed very modest levels of variation between the readmission models (HIDI GEM-mapped and CMSYale ICD-910 compliant)
27
Whatrsquos Coming after HIINJessica Stultz
28
Missouri Harm Dashboard
29
Missouri Harm Dashboard
MHA board initiative
Three harms
CAUTI
CLABSI
CDI
Reduce state rate by 10 percent
30
Missouri Harm Dashboard
All Missouri acute care hospitals
Excludes rehab psych LTAC womenrsquos childrens specialty veteransmilitary
Distributed to CEOs quarterly
2017 Q4 dashboard was distributed at district council last week
Targeted education materials to be sent at the leadership level
31
Missouri Harm Dashboard
Includes NHSN data only
Measuring improvement of rates
Most recent SIR will be shown on dashboard
Measuring improvement over state target
Calendar year 2016 baseline
Data will be pulled quarterly
2017 Q4 distributed March 2018
2018 Q1 will be distributed June 2018
32
33
HIIN Regional Boot Camps
To Increase Workersrsquo Safety
34
What to Expect
Attendees will be taught and have the opportunity to demonstrate
De-escalation management
Crisis intervention training to supplement the de-escalation techniques with a focus on mental health populations
Components of rape aggression defense training will be taught to offer realistic self-defense tactics and techniques
35
What to Expect
A holistic approach to reducing both the risk and anxiety surrounding violence in healthcare
Excellent supplement to existing safety programs already in place at your organizations
Offered at no cost to Missouri HRET-HIIN hospitals
Audience
front line staff in all care units (ED critical care and medical-surgical units)
safety and security personnel36
Locations and Times
Workplace safety
Blue Springs
ndash April 11 2018 at the Courtyard Marriott ndash Adams Pointe Conference Center
Springfield
ndash April 25 2018 at the Oasis Hotel and Convention Center
St Charles
ndash May 2 2018 at the Embassy Suites Hotel
Cape Girardeau
ndash May 9 2018 at the Drury Plaza Hotel Conference Center
37
HIIN Project Updates
38
Data Due Dates mdash HIIN Project Year 2
39
MHA ldquoZero Heroesrdquo Club
MHA congratulates the following HIIN-participating hospitals with the most zero harm measures reported These organizations have either achieved andor sustained a zero rate of harm and are in the top 10 percent of HIIN-participating hospitals Congratulations to the ldquoZero Herosrdquo for the month of September
Carroll County Memorial Hospital
Ellett Memorial Hospital
Harrison County Community Hospital
Iron County Medical Center
Osage Beach Center for Cognitive Disorders
Pike County Memorial Hospital
Southeast Health Center of Ripley County
Sullivan County Memorial Hospital
40
AHArsquos IT department investigated the emails and discovered they were generated by groups from Germany and Switzerland AHA recommends that your IT department block emails from these two countries unless you do business with them
SPAM Email from HEN or HIIN Finance mdash PLEASE IGNORE
If you receive an email asking you to pay your invoice via a link please ignore and permanently delete Do not click on the link in the email The email may come from different email addresses but is titled as HENHIIN Finance or HRET HIIN similar to what is pictured below
41
Hospital Leadership and Quality Assessment Tool
The tool measures board members C-suite executives and managementsupervisors on how well they are implementing evidence-based practices shown to support a culture of safety and high performance in clinical quality measures
No front-line staff survey component
Survey content
FAQ
42
HLQAT Survey
MHA is providing this complimentary opportunity for all HIIN hospitals to access and utilize this survey
Two options
Phase I mdash Completed
Phase II mdash April through August 2018
ndash Available to all HIIN hospitals mdash previous participation not
required
ndash Phase I hospitals may participate in phase II if desired
ndash Intent to participate materials will be sent to HIIN contacts soon
43
Qualaris Audit Tool Projects
Hand Hygiene
Culture of Safety Rounding
Sepsis
ReadmissionsCare Transitions
44
Qualaris mdash New Tools
Qualaris has new tools to assist users with coordinating successful improvement projects
Tracking project outcomes alongside process measures
Real-time dashboards inclusive of both outcomes and process measures
Documenting PDSAs
Click here to view the Qualaris improvement projects and outcomes demo
These tools require a short setup webinar session with Qualaris
Readmission Immersion Project participants should contact supportqualariscom
Use the Qualaris virtual chat support for next steps
45
LEAN Six Sigma Green Belt Project
Project launching mdashMarch 13 2018 through November 30 2018
Hospitals committed mdash20
Topic-focused
Patient throughput
ICU harm reduction
Errors in medication reconciliation
46
Capital Region Medical Center
Carroll County Memorial Hospital
Cass Regional Medical Center
Cox Medical Center
Fitzgibbon Hospital
Golden Valley Memorial Healthcare
Hannibal Regional Hospital
Lafayette Regional Health Center
Lake Regional Health System
Liberty Hospital
North Kansas City Hospital
Ozark Medical Center
Perry County Memorial Hospital
Saint Lukes Health System
Saint Lukes Hospital Kansas City
Scotland County Hospital
Southeast Missouri Hospital
St Marys Medical Center
Ste Genevieve County Memorial Hospital
Western Missouri Medical Center
NHSN Reporting Facilities
The January 23rd release of the NHSN 881 application will introduce an updated NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled in NHSN prior to December 2 2017 Facilities that enrolled in NHSN on or after December 2 2017 have already accessed this new Consent and will not need to accept it again if they have already done so
Primary Contacts or Facility Administrators should agree to this updated Consent form for each component by April 14th 2018 or risk losing access to NHSN
An alert will appear on all NHSN component home pages and primary contacts and facility administrators will receive an email notification
Additional information including Frequently Asked Questions and the updated NHSN purposes are available on CDCs NHSN website If you have any questions please send an email to NHSNcdcgov with the subject line ldquoNHSN Reconsentrdquo
47
NHSN Reporting Facilities
The NHSN team has published informational guidance on our website to assist users with completion of the updated NHSN Agreement to Participate and Consent A 5-minute video informs users of the new Consent purposes and the simple process for accepting the Consent electronically Furthermore a step-by-step guidance document provides detailed instructions and screen shots for what Facility Administrators and Primary Contacts can expect to see when they begin the re-consent process in the NHSN application A link to the video and the guidance document can both be found in the FAQs About NHSNrsquos Agreement to Participate and Consent
48
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
CABG Readmission
13
HF Readmission
14
COPD Readmission
15
Pneumonia Readmission
16
Solution Approach
Patients are risk stratified per the Modified Lace Tool
Focus is on high risk patients
Disease specific education with daily teach back method
Nursing Home Collaboration for high risk heart failure patients
Transition Care Nurses make visits to local nursing homes
SSM Home Connections visits to nursing homes in rural nursing homes
17
Solution Approach
Pharmacy admission and discharge medication reconciliation and disease specific education
Multi-disciplinary discharge planning on admission
Standing orderset used to place appropriate consults
Daily flash rounds to discuss discharge planning with a multidisciplinary team
18
Solution Approach
Daily meeting with SSM Home Health to review high risk patients
Daily assessment and report potential hazards for readmission to physician
Structured telephone program
Data collection to track leading indicators
Daily readmission report out for the GEMBA program
Weekly readmission RCA
19
Solution Approach
Weekly Core Team Meetings
Implemented on 21517 and ongoing currently
Root cause analysis on each readmission with action planinitiatives reviewedimplemented
Review status on all nursing home patientsvisits and address concerns and identify opportunities
Review at risk patients that are at home and address concerns and identify opportunities
Review leading and lagging indicators and address concerns and identify opportunities
Update on current corrective actions20
Test of ChangeRapid Experiment
Follow up appointment with physician within 5 business days to 100 in 2017
Improve patient actually attending the follow up appointment to 100 in 2017
Home health visits within 24 hours with front loading of visits 100 in 2017
Improve Medication Reconciliation on admission and discharge for all 5 diseases to 100 in 2017
21
Completion Plan
As of June 2017 scales can be provided for low income heart failure patients upon discharge
20172018 Development Projects
Robust palliative care program
Meal delivery program
Rescue Clinic
Improve physician engagement
Enhanced collaboration with LSS and Stonebridge (Quarterly meetings scheduled)
Palliative Care Program (Sub Team developing proposal)
Consider Code HF program (ED Implementation)
22
Confirmed State
Decrease HF readmissions from 202 in 2016 to 153 in 2017
Decrease COPD readmissions 198 in 2016 to 144 in 2017
Decrease PN readmissions from 122 in 2016 to 114 in 2017
Maintain AMI and CABG readmissions at better than the 90th percentile in 2017
23
Questions
24
Readmissions UpdateJosh Grotzinger
25
ICD-10 Readmission Update
October 2015 HIDI developed a GEM-mapped approach to the CMSYale risk-adjusted readmission models to accommodate ICD-9 and ICD-10 codes This action was taken prior to the availability of final ICD-910 compliant models from CMSYale to ensure continuity of readmission reporting for HIDI-participating hospitals
CMSYale released new ICD-910 compliant risk-adjusted readmission models with the release of the 2017 Hospital Compare data
26
CMSYale Documentation
CMSYale have validated their ICD-910 compliant models with documentation on QualityNet
Documentation on additionsexclusions from the cohort definitions are available through CMSYale on QualityNet
HIDI observed very modest levels of variation between the readmission models (HIDI GEM-mapped and CMSYale ICD-910 compliant)
27
Whatrsquos Coming after HIINJessica Stultz
28
Missouri Harm Dashboard
29
Missouri Harm Dashboard
MHA board initiative
Three harms
CAUTI
CLABSI
CDI
Reduce state rate by 10 percent
30
Missouri Harm Dashboard
All Missouri acute care hospitals
Excludes rehab psych LTAC womenrsquos childrens specialty veteransmilitary
Distributed to CEOs quarterly
2017 Q4 dashboard was distributed at district council last week
Targeted education materials to be sent at the leadership level
31
Missouri Harm Dashboard
Includes NHSN data only
Measuring improvement of rates
Most recent SIR will be shown on dashboard
Measuring improvement over state target
Calendar year 2016 baseline
Data will be pulled quarterly
2017 Q4 distributed March 2018
2018 Q1 will be distributed June 2018
32
33
HIIN Regional Boot Camps
To Increase Workersrsquo Safety
34
What to Expect
Attendees will be taught and have the opportunity to demonstrate
De-escalation management
Crisis intervention training to supplement the de-escalation techniques with a focus on mental health populations
Components of rape aggression defense training will be taught to offer realistic self-defense tactics and techniques
35
What to Expect
A holistic approach to reducing both the risk and anxiety surrounding violence in healthcare
Excellent supplement to existing safety programs already in place at your organizations
Offered at no cost to Missouri HRET-HIIN hospitals
Audience
front line staff in all care units (ED critical care and medical-surgical units)
safety and security personnel36
Locations and Times
Workplace safety
Blue Springs
ndash April 11 2018 at the Courtyard Marriott ndash Adams Pointe Conference Center
Springfield
ndash April 25 2018 at the Oasis Hotel and Convention Center
St Charles
ndash May 2 2018 at the Embassy Suites Hotel
Cape Girardeau
ndash May 9 2018 at the Drury Plaza Hotel Conference Center
37
HIIN Project Updates
38
Data Due Dates mdash HIIN Project Year 2
39
MHA ldquoZero Heroesrdquo Club
MHA congratulates the following HIIN-participating hospitals with the most zero harm measures reported These organizations have either achieved andor sustained a zero rate of harm and are in the top 10 percent of HIIN-participating hospitals Congratulations to the ldquoZero Herosrdquo for the month of September
Carroll County Memorial Hospital
Ellett Memorial Hospital
Harrison County Community Hospital
Iron County Medical Center
Osage Beach Center for Cognitive Disorders
Pike County Memorial Hospital
Southeast Health Center of Ripley County
Sullivan County Memorial Hospital
40
AHArsquos IT department investigated the emails and discovered they were generated by groups from Germany and Switzerland AHA recommends that your IT department block emails from these two countries unless you do business with them
SPAM Email from HEN or HIIN Finance mdash PLEASE IGNORE
If you receive an email asking you to pay your invoice via a link please ignore and permanently delete Do not click on the link in the email The email may come from different email addresses but is titled as HENHIIN Finance or HRET HIIN similar to what is pictured below
41
Hospital Leadership and Quality Assessment Tool
The tool measures board members C-suite executives and managementsupervisors on how well they are implementing evidence-based practices shown to support a culture of safety and high performance in clinical quality measures
No front-line staff survey component
Survey content
FAQ
42
HLQAT Survey
MHA is providing this complimentary opportunity for all HIIN hospitals to access and utilize this survey
Two options
Phase I mdash Completed
Phase II mdash April through August 2018
ndash Available to all HIIN hospitals mdash previous participation not
required
ndash Phase I hospitals may participate in phase II if desired
ndash Intent to participate materials will be sent to HIIN contacts soon
43
Qualaris Audit Tool Projects
Hand Hygiene
Culture of Safety Rounding
Sepsis
ReadmissionsCare Transitions
44
Qualaris mdash New Tools
Qualaris has new tools to assist users with coordinating successful improvement projects
Tracking project outcomes alongside process measures
Real-time dashboards inclusive of both outcomes and process measures
Documenting PDSAs
Click here to view the Qualaris improvement projects and outcomes demo
These tools require a short setup webinar session with Qualaris
Readmission Immersion Project participants should contact supportqualariscom
Use the Qualaris virtual chat support for next steps
45
LEAN Six Sigma Green Belt Project
Project launching mdashMarch 13 2018 through November 30 2018
Hospitals committed mdash20
Topic-focused
Patient throughput
ICU harm reduction
Errors in medication reconciliation
46
Capital Region Medical Center
Carroll County Memorial Hospital
Cass Regional Medical Center
Cox Medical Center
Fitzgibbon Hospital
Golden Valley Memorial Healthcare
Hannibal Regional Hospital
Lafayette Regional Health Center
Lake Regional Health System
Liberty Hospital
North Kansas City Hospital
Ozark Medical Center
Perry County Memorial Hospital
Saint Lukes Health System
Saint Lukes Hospital Kansas City
Scotland County Hospital
Southeast Missouri Hospital
St Marys Medical Center
Ste Genevieve County Memorial Hospital
Western Missouri Medical Center
NHSN Reporting Facilities
The January 23rd release of the NHSN 881 application will introduce an updated NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled in NHSN prior to December 2 2017 Facilities that enrolled in NHSN on or after December 2 2017 have already accessed this new Consent and will not need to accept it again if they have already done so
Primary Contacts or Facility Administrators should agree to this updated Consent form for each component by April 14th 2018 or risk losing access to NHSN
An alert will appear on all NHSN component home pages and primary contacts and facility administrators will receive an email notification
Additional information including Frequently Asked Questions and the updated NHSN purposes are available on CDCs NHSN website If you have any questions please send an email to NHSNcdcgov with the subject line ldquoNHSN Reconsentrdquo
47
NHSN Reporting Facilities
The NHSN team has published informational guidance on our website to assist users with completion of the updated NHSN Agreement to Participate and Consent A 5-minute video informs users of the new Consent purposes and the simple process for accepting the Consent electronically Furthermore a step-by-step guidance document provides detailed instructions and screen shots for what Facility Administrators and Primary Contacts can expect to see when they begin the re-consent process in the NHSN application A link to the video and the guidance document can both be found in the FAQs About NHSNrsquos Agreement to Participate and Consent
48
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
HF Readmission
14
COPD Readmission
15
Pneumonia Readmission
16
Solution Approach
Patients are risk stratified per the Modified Lace Tool
Focus is on high risk patients
Disease specific education with daily teach back method
Nursing Home Collaboration for high risk heart failure patients
Transition Care Nurses make visits to local nursing homes
SSM Home Connections visits to nursing homes in rural nursing homes
17
Solution Approach
Pharmacy admission and discharge medication reconciliation and disease specific education
Multi-disciplinary discharge planning on admission
Standing orderset used to place appropriate consults
Daily flash rounds to discuss discharge planning with a multidisciplinary team
18
Solution Approach
Daily meeting with SSM Home Health to review high risk patients
Daily assessment and report potential hazards for readmission to physician
Structured telephone program
Data collection to track leading indicators
Daily readmission report out for the GEMBA program
Weekly readmission RCA
19
Solution Approach
Weekly Core Team Meetings
Implemented on 21517 and ongoing currently
Root cause analysis on each readmission with action planinitiatives reviewedimplemented
Review status on all nursing home patientsvisits and address concerns and identify opportunities
Review at risk patients that are at home and address concerns and identify opportunities
Review leading and lagging indicators and address concerns and identify opportunities
Update on current corrective actions20
Test of ChangeRapid Experiment
Follow up appointment with physician within 5 business days to 100 in 2017
Improve patient actually attending the follow up appointment to 100 in 2017
Home health visits within 24 hours with front loading of visits 100 in 2017
Improve Medication Reconciliation on admission and discharge for all 5 diseases to 100 in 2017
21
Completion Plan
As of June 2017 scales can be provided for low income heart failure patients upon discharge
20172018 Development Projects
Robust palliative care program
Meal delivery program
Rescue Clinic
Improve physician engagement
Enhanced collaboration with LSS and Stonebridge (Quarterly meetings scheduled)
Palliative Care Program (Sub Team developing proposal)
Consider Code HF program (ED Implementation)
22
Confirmed State
Decrease HF readmissions from 202 in 2016 to 153 in 2017
Decrease COPD readmissions 198 in 2016 to 144 in 2017
Decrease PN readmissions from 122 in 2016 to 114 in 2017
Maintain AMI and CABG readmissions at better than the 90th percentile in 2017
23
Questions
24
Readmissions UpdateJosh Grotzinger
25
ICD-10 Readmission Update
October 2015 HIDI developed a GEM-mapped approach to the CMSYale risk-adjusted readmission models to accommodate ICD-9 and ICD-10 codes This action was taken prior to the availability of final ICD-910 compliant models from CMSYale to ensure continuity of readmission reporting for HIDI-participating hospitals
CMSYale released new ICD-910 compliant risk-adjusted readmission models with the release of the 2017 Hospital Compare data
26
CMSYale Documentation
CMSYale have validated their ICD-910 compliant models with documentation on QualityNet
Documentation on additionsexclusions from the cohort definitions are available through CMSYale on QualityNet
HIDI observed very modest levels of variation between the readmission models (HIDI GEM-mapped and CMSYale ICD-910 compliant)
27
Whatrsquos Coming after HIINJessica Stultz
28
Missouri Harm Dashboard
29
Missouri Harm Dashboard
MHA board initiative
Three harms
CAUTI
CLABSI
CDI
Reduce state rate by 10 percent
30
Missouri Harm Dashboard
All Missouri acute care hospitals
Excludes rehab psych LTAC womenrsquos childrens specialty veteransmilitary
Distributed to CEOs quarterly
2017 Q4 dashboard was distributed at district council last week
Targeted education materials to be sent at the leadership level
31
Missouri Harm Dashboard
Includes NHSN data only
Measuring improvement of rates
Most recent SIR will be shown on dashboard
Measuring improvement over state target
Calendar year 2016 baseline
Data will be pulled quarterly
2017 Q4 distributed March 2018
2018 Q1 will be distributed June 2018
32
33
HIIN Regional Boot Camps
To Increase Workersrsquo Safety
34
What to Expect
Attendees will be taught and have the opportunity to demonstrate
De-escalation management
Crisis intervention training to supplement the de-escalation techniques with a focus on mental health populations
Components of rape aggression defense training will be taught to offer realistic self-defense tactics and techniques
35
What to Expect
A holistic approach to reducing both the risk and anxiety surrounding violence in healthcare
Excellent supplement to existing safety programs already in place at your organizations
Offered at no cost to Missouri HRET-HIIN hospitals
Audience
front line staff in all care units (ED critical care and medical-surgical units)
safety and security personnel36
Locations and Times
Workplace safety
Blue Springs
ndash April 11 2018 at the Courtyard Marriott ndash Adams Pointe Conference Center
Springfield
ndash April 25 2018 at the Oasis Hotel and Convention Center
St Charles
ndash May 2 2018 at the Embassy Suites Hotel
Cape Girardeau
ndash May 9 2018 at the Drury Plaza Hotel Conference Center
37
HIIN Project Updates
38
Data Due Dates mdash HIIN Project Year 2
39
MHA ldquoZero Heroesrdquo Club
MHA congratulates the following HIIN-participating hospitals with the most zero harm measures reported These organizations have either achieved andor sustained a zero rate of harm and are in the top 10 percent of HIIN-participating hospitals Congratulations to the ldquoZero Herosrdquo for the month of September
Carroll County Memorial Hospital
Ellett Memorial Hospital
Harrison County Community Hospital
Iron County Medical Center
Osage Beach Center for Cognitive Disorders
Pike County Memorial Hospital
Southeast Health Center of Ripley County
Sullivan County Memorial Hospital
40
AHArsquos IT department investigated the emails and discovered they were generated by groups from Germany and Switzerland AHA recommends that your IT department block emails from these two countries unless you do business with them
SPAM Email from HEN or HIIN Finance mdash PLEASE IGNORE
If you receive an email asking you to pay your invoice via a link please ignore and permanently delete Do not click on the link in the email The email may come from different email addresses but is titled as HENHIIN Finance or HRET HIIN similar to what is pictured below
41
Hospital Leadership and Quality Assessment Tool
The tool measures board members C-suite executives and managementsupervisors on how well they are implementing evidence-based practices shown to support a culture of safety and high performance in clinical quality measures
No front-line staff survey component
Survey content
FAQ
42
HLQAT Survey
MHA is providing this complimentary opportunity for all HIIN hospitals to access and utilize this survey
Two options
Phase I mdash Completed
Phase II mdash April through August 2018
ndash Available to all HIIN hospitals mdash previous participation not
required
ndash Phase I hospitals may participate in phase II if desired
ndash Intent to participate materials will be sent to HIIN contacts soon
43
Qualaris Audit Tool Projects
Hand Hygiene
Culture of Safety Rounding
Sepsis
ReadmissionsCare Transitions
44
Qualaris mdash New Tools
Qualaris has new tools to assist users with coordinating successful improvement projects
Tracking project outcomes alongside process measures
Real-time dashboards inclusive of both outcomes and process measures
Documenting PDSAs
Click here to view the Qualaris improvement projects and outcomes demo
These tools require a short setup webinar session with Qualaris
Readmission Immersion Project participants should contact supportqualariscom
Use the Qualaris virtual chat support for next steps
45
LEAN Six Sigma Green Belt Project
Project launching mdashMarch 13 2018 through November 30 2018
Hospitals committed mdash20
Topic-focused
Patient throughput
ICU harm reduction
Errors in medication reconciliation
46
Capital Region Medical Center
Carroll County Memorial Hospital
Cass Regional Medical Center
Cox Medical Center
Fitzgibbon Hospital
Golden Valley Memorial Healthcare
Hannibal Regional Hospital
Lafayette Regional Health Center
Lake Regional Health System
Liberty Hospital
North Kansas City Hospital
Ozark Medical Center
Perry County Memorial Hospital
Saint Lukes Health System
Saint Lukes Hospital Kansas City
Scotland County Hospital
Southeast Missouri Hospital
St Marys Medical Center
Ste Genevieve County Memorial Hospital
Western Missouri Medical Center
NHSN Reporting Facilities
The January 23rd release of the NHSN 881 application will introduce an updated NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled in NHSN prior to December 2 2017 Facilities that enrolled in NHSN on or after December 2 2017 have already accessed this new Consent and will not need to accept it again if they have already done so
Primary Contacts or Facility Administrators should agree to this updated Consent form for each component by April 14th 2018 or risk losing access to NHSN
An alert will appear on all NHSN component home pages and primary contacts and facility administrators will receive an email notification
Additional information including Frequently Asked Questions and the updated NHSN purposes are available on CDCs NHSN website If you have any questions please send an email to NHSNcdcgov with the subject line ldquoNHSN Reconsentrdquo
47
NHSN Reporting Facilities
The NHSN team has published informational guidance on our website to assist users with completion of the updated NHSN Agreement to Participate and Consent A 5-minute video informs users of the new Consent purposes and the simple process for accepting the Consent electronically Furthermore a step-by-step guidance document provides detailed instructions and screen shots for what Facility Administrators and Primary Contacts can expect to see when they begin the re-consent process in the NHSN application A link to the video and the guidance document can both be found in the FAQs About NHSNrsquos Agreement to Participate and Consent
48
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
COPD Readmission
15
Pneumonia Readmission
16
Solution Approach
Patients are risk stratified per the Modified Lace Tool
Focus is on high risk patients
Disease specific education with daily teach back method
Nursing Home Collaboration for high risk heart failure patients
Transition Care Nurses make visits to local nursing homes
SSM Home Connections visits to nursing homes in rural nursing homes
17
Solution Approach
Pharmacy admission and discharge medication reconciliation and disease specific education
Multi-disciplinary discharge planning on admission
Standing orderset used to place appropriate consults
Daily flash rounds to discuss discharge planning with a multidisciplinary team
18
Solution Approach
Daily meeting with SSM Home Health to review high risk patients
Daily assessment and report potential hazards for readmission to physician
Structured telephone program
Data collection to track leading indicators
Daily readmission report out for the GEMBA program
Weekly readmission RCA
19
Solution Approach
Weekly Core Team Meetings
Implemented on 21517 and ongoing currently
Root cause analysis on each readmission with action planinitiatives reviewedimplemented
Review status on all nursing home patientsvisits and address concerns and identify opportunities
Review at risk patients that are at home and address concerns and identify opportunities
Review leading and lagging indicators and address concerns and identify opportunities
Update on current corrective actions20
Test of ChangeRapid Experiment
Follow up appointment with physician within 5 business days to 100 in 2017
Improve patient actually attending the follow up appointment to 100 in 2017
Home health visits within 24 hours with front loading of visits 100 in 2017
Improve Medication Reconciliation on admission and discharge for all 5 diseases to 100 in 2017
21
Completion Plan
As of June 2017 scales can be provided for low income heart failure patients upon discharge
20172018 Development Projects
Robust palliative care program
Meal delivery program
Rescue Clinic
Improve physician engagement
Enhanced collaboration with LSS and Stonebridge (Quarterly meetings scheduled)
Palliative Care Program (Sub Team developing proposal)
Consider Code HF program (ED Implementation)
22
Confirmed State
Decrease HF readmissions from 202 in 2016 to 153 in 2017
Decrease COPD readmissions 198 in 2016 to 144 in 2017
Decrease PN readmissions from 122 in 2016 to 114 in 2017
Maintain AMI and CABG readmissions at better than the 90th percentile in 2017
23
Questions
24
Readmissions UpdateJosh Grotzinger
25
ICD-10 Readmission Update
October 2015 HIDI developed a GEM-mapped approach to the CMSYale risk-adjusted readmission models to accommodate ICD-9 and ICD-10 codes This action was taken prior to the availability of final ICD-910 compliant models from CMSYale to ensure continuity of readmission reporting for HIDI-participating hospitals
CMSYale released new ICD-910 compliant risk-adjusted readmission models with the release of the 2017 Hospital Compare data
26
CMSYale Documentation
CMSYale have validated their ICD-910 compliant models with documentation on QualityNet
Documentation on additionsexclusions from the cohort definitions are available through CMSYale on QualityNet
HIDI observed very modest levels of variation between the readmission models (HIDI GEM-mapped and CMSYale ICD-910 compliant)
27
Whatrsquos Coming after HIINJessica Stultz
28
Missouri Harm Dashboard
29
Missouri Harm Dashboard
MHA board initiative
Three harms
CAUTI
CLABSI
CDI
Reduce state rate by 10 percent
30
Missouri Harm Dashboard
All Missouri acute care hospitals
Excludes rehab psych LTAC womenrsquos childrens specialty veteransmilitary
Distributed to CEOs quarterly
2017 Q4 dashboard was distributed at district council last week
Targeted education materials to be sent at the leadership level
31
Missouri Harm Dashboard
Includes NHSN data only
Measuring improvement of rates
Most recent SIR will be shown on dashboard
Measuring improvement over state target
Calendar year 2016 baseline
Data will be pulled quarterly
2017 Q4 distributed March 2018
2018 Q1 will be distributed June 2018
32
33
HIIN Regional Boot Camps
To Increase Workersrsquo Safety
34
What to Expect
Attendees will be taught and have the opportunity to demonstrate
De-escalation management
Crisis intervention training to supplement the de-escalation techniques with a focus on mental health populations
Components of rape aggression defense training will be taught to offer realistic self-defense tactics and techniques
35
What to Expect
A holistic approach to reducing both the risk and anxiety surrounding violence in healthcare
Excellent supplement to existing safety programs already in place at your organizations
Offered at no cost to Missouri HRET-HIIN hospitals
Audience
front line staff in all care units (ED critical care and medical-surgical units)
safety and security personnel36
Locations and Times
Workplace safety
Blue Springs
ndash April 11 2018 at the Courtyard Marriott ndash Adams Pointe Conference Center
Springfield
ndash April 25 2018 at the Oasis Hotel and Convention Center
St Charles
ndash May 2 2018 at the Embassy Suites Hotel
Cape Girardeau
ndash May 9 2018 at the Drury Plaza Hotel Conference Center
37
HIIN Project Updates
38
Data Due Dates mdash HIIN Project Year 2
39
MHA ldquoZero Heroesrdquo Club
MHA congratulates the following HIIN-participating hospitals with the most zero harm measures reported These organizations have either achieved andor sustained a zero rate of harm and are in the top 10 percent of HIIN-participating hospitals Congratulations to the ldquoZero Herosrdquo for the month of September
Carroll County Memorial Hospital
Ellett Memorial Hospital
Harrison County Community Hospital
Iron County Medical Center
Osage Beach Center for Cognitive Disorders
Pike County Memorial Hospital
Southeast Health Center of Ripley County
Sullivan County Memorial Hospital
40
AHArsquos IT department investigated the emails and discovered they were generated by groups from Germany and Switzerland AHA recommends that your IT department block emails from these two countries unless you do business with them
SPAM Email from HEN or HIIN Finance mdash PLEASE IGNORE
If you receive an email asking you to pay your invoice via a link please ignore and permanently delete Do not click on the link in the email The email may come from different email addresses but is titled as HENHIIN Finance or HRET HIIN similar to what is pictured below
41
Hospital Leadership and Quality Assessment Tool
The tool measures board members C-suite executives and managementsupervisors on how well they are implementing evidence-based practices shown to support a culture of safety and high performance in clinical quality measures
No front-line staff survey component
Survey content
FAQ
42
HLQAT Survey
MHA is providing this complimentary opportunity for all HIIN hospitals to access and utilize this survey
Two options
Phase I mdash Completed
Phase II mdash April through August 2018
ndash Available to all HIIN hospitals mdash previous participation not
required
ndash Phase I hospitals may participate in phase II if desired
ndash Intent to participate materials will be sent to HIIN contacts soon
43
Qualaris Audit Tool Projects
Hand Hygiene
Culture of Safety Rounding
Sepsis
ReadmissionsCare Transitions
44
Qualaris mdash New Tools
Qualaris has new tools to assist users with coordinating successful improvement projects
Tracking project outcomes alongside process measures
Real-time dashboards inclusive of both outcomes and process measures
Documenting PDSAs
Click here to view the Qualaris improvement projects and outcomes demo
These tools require a short setup webinar session with Qualaris
Readmission Immersion Project participants should contact supportqualariscom
Use the Qualaris virtual chat support for next steps
45
LEAN Six Sigma Green Belt Project
Project launching mdashMarch 13 2018 through November 30 2018
Hospitals committed mdash20
Topic-focused
Patient throughput
ICU harm reduction
Errors in medication reconciliation
46
Capital Region Medical Center
Carroll County Memorial Hospital
Cass Regional Medical Center
Cox Medical Center
Fitzgibbon Hospital
Golden Valley Memorial Healthcare
Hannibal Regional Hospital
Lafayette Regional Health Center
Lake Regional Health System
Liberty Hospital
North Kansas City Hospital
Ozark Medical Center
Perry County Memorial Hospital
Saint Lukes Health System
Saint Lukes Hospital Kansas City
Scotland County Hospital
Southeast Missouri Hospital
St Marys Medical Center
Ste Genevieve County Memorial Hospital
Western Missouri Medical Center
NHSN Reporting Facilities
The January 23rd release of the NHSN 881 application will introduce an updated NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled in NHSN prior to December 2 2017 Facilities that enrolled in NHSN on or after December 2 2017 have already accessed this new Consent and will not need to accept it again if they have already done so
Primary Contacts or Facility Administrators should agree to this updated Consent form for each component by April 14th 2018 or risk losing access to NHSN
An alert will appear on all NHSN component home pages and primary contacts and facility administrators will receive an email notification
Additional information including Frequently Asked Questions and the updated NHSN purposes are available on CDCs NHSN website If you have any questions please send an email to NHSNcdcgov with the subject line ldquoNHSN Reconsentrdquo
47
NHSN Reporting Facilities
The NHSN team has published informational guidance on our website to assist users with completion of the updated NHSN Agreement to Participate and Consent A 5-minute video informs users of the new Consent purposes and the simple process for accepting the Consent electronically Furthermore a step-by-step guidance document provides detailed instructions and screen shots for what Facility Administrators and Primary Contacts can expect to see when they begin the re-consent process in the NHSN application A link to the video and the guidance document can both be found in the FAQs About NHSNrsquos Agreement to Participate and Consent
48
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
Pneumonia Readmission
16
Solution Approach
Patients are risk stratified per the Modified Lace Tool
Focus is on high risk patients
Disease specific education with daily teach back method
Nursing Home Collaboration for high risk heart failure patients
Transition Care Nurses make visits to local nursing homes
SSM Home Connections visits to nursing homes in rural nursing homes
17
Solution Approach
Pharmacy admission and discharge medication reconciliation and disease specific education
Multi-disciplinary discharge planning on admission
Standing orderset used to place appropriate consults
Daily flash rounds to discuss discharge planning with a multidisciplinary team
18
Solution Approach
Daily meeting with SSM Home Health to review high risk patients
Daily assessment and report potential hazards for readmission to physician
Structured telephone program
Data collection to track leading indicators
Daily readmission report out for the GEMBA program
Weekly readmission RCA
19
Solution Approach
Weekly Core Team Meetings
Implemented on 21517 and ongoing currently
Root cause analysis on each readmission with action planinitiatives reviewedimplemented
Review status on all nursing home patientsvisits and address concerns and identify opportunities
Review at risk patients that are at home and address concerns and identify opportunities
Review leading and lagging indicators and address concerns and identify opportunities
Update on current corrective actions20
Test of ChangeRapid Experiment
Follow up appointment with physician within 5 business days to 100 in 2017
Improve patient actually attending the follow up appointment to 100 in 2017
Home health visits within 24 hours with front loading of visits 100 in 2017
Improve Medication Reconciliation on admission and discharge for all 5 diseases to 100 in 2017
21
Completion Plan
As of June 2017 scales can be provided for low income heart failure patients upon discharge
20172018 Development Projects
Robust palliative care program
Meal delivery program
Rescue Clinic
Improve physician engagement
Enhanced collaboration with LSS and Stonebridge (Quarterly meetings scheduled)
Palliative Care Program (Sub Team developing proposal)
Consider Code HF program (ED Implementation)
22
Confirmed State
Decrease HF readmissions from 202 in 2016 to 153 in 2017
Decrease COPD readmissions 198 in 2016 to 144 in 2017
Decrease PN readmissions from 122 in 2016 to 114 in 2017
Maintain AMI and CABG readmissions at better than the 90th percentile in 2017
23
Questions
24
Readmissions UpdateJosh Grotzinger
25
ICD-10 Readmission Update
October 2015 HIDI developed a GEM-mapped approach to the CMSYale risk-adjusted readmission models to accommodate ICD-9 and ICD-10 codes This action was taken prior to the availability of final ICD-910 compliant models from CMSYale to ensure continuity of readmission reporting for HIDI-participating hospitals
CMSYale released new ICD-910 compliant risk-adjusted readmission models with the release of the 2017 Hospital Compare data
26
CMSYale Documentation
CMSYale have validated their ICD-910 compliant models with documentation on QualityNet
Documentation on additionsexclusions from the cohort definitions are available through CMSYale on QualityNet
HIDI observed very modest levels of variation between the readmission models (HIDI GEM-mapped and CMSYale ICD-910 compliant)
27
Whatrsquos Coming after HIINJessica Stultz
28
Missouri Harm Dashboard
29
Missouri Harm Dashboard
MHA board initiative
Three harms
CAUTI
CLABSI
CDI
Reduce state rate by 10 percent
30
Missouri Harm Dashboard
All Missouri acute care hospitals
Excludes rehab psych LTAC womenrsquos childrens specialty veteransmilitary
Distributed to CEOs quarterly
2017 Q4 dashboard was distributed at district council last week
Targeted education materials to be sent at the leadership level
31
Missouri Harm Dashboard
Includes NHSN data only
Measuring improvement of rates
Most recent SIR will be shown on dashboard
Measuring improvement over state target
Calendar year 2016 baseline
Data will be pulled quarterly
2017 Q4 distributed March 2018
2018 Q1 will be distributed June 2018
32
33
HIIN Regional Boot Camps
To Increase Workersrsquo Safety
34
What to Expect
Attendees will be taught and have the opportunity to demonstrate
De-escalation management
Crisis intervention training to supplement the de-escalation techniques with a focus on mental health populations
Components of rape aggression defense training will be taught to offer realistic self-defense tactics and techniques
35
What to Expect
A holistic approach to reducing both the risk and anxiety surrounding violence in healthcare
Excellent supplement to existing safety programs already in place at your organizations
Offered at no cost to Missouri HRET-HIIN hospitals
Audience
front line staff in all care units (ED critical care and medical-surgical units)
safety and security personnel36
Locations and Times
Workplace safety
Blue Springs
ndash April 11 2018 at the Courtyard Marriott ndash Adams Pointe Conference Center
Springfield
ndash April 25 2018 at the Oasis Hotel and Convention Center
St Charles
ndash May 2 2018 at the Embassy Suites Hotel
Cape Girardeau
ndash May 9 2018 at the Drury Plaza Hotel Conference Center
37
HIIN Project Updates
38
Data Due Dates mdash HIIN Project Year 2
39
MHA ldquoZero Heroesrdquo Club
MHA congratulates the following HIIN-participating hospitals with the most zero harm measures reported These organizations have either achieved andor sustained a zero rate of harm and are in the top 10 percent of HIIN-participating hospitals Congratulations to the ldquoZero Herosrdquo for the month of September
Carroll County Memorial Hospital
Ellett Memorial Hospital
Harrison County Community Hospital
Iron County Medical Center
Osage Beach Center for Cognitive Disorders
Pike County Memorial Hospital
Southeast Health Center of Ripley County
Sullivan County Memorial Hospital
40
AHArsquos IT department investigated the emails and discovered they were generated by groups from Germany and Switzerland AHA recommends that your IT department block emails from these two countries unless you do business with them
SPAM Email from HEN or HIIN Finance mdash PLEASE IGNORE
If you receive an email asking you to pay your invoice via a link please ignore and permanently delete Do not click on the link in the email The email may come from different email addresses but is titled as HENHIIN Finance or HRET HIIN similar to what is pictured below
41
Hospital Leadership and Quality Assessment Tool
The tool measures board members C-suite executives and managementsupervisors on how well they are implementing evidence-based practices shown to support a culture of safety and high performance in clinical quality measures
No front-line staff survey component
Survey content
FAQ
42
HLQAT Survey
MHA is providing this complimentary opportunity for all HIIN hospitals to access and utilize this survey
Two options
Phase I mdash Completed
Phase II mdash April through August 2018
ndash Available to all HIIN hospitals mdash previous participation not
required
ndash Phase I hospitals may participate in phase II if desired
ndash Intent to participate materials will be sent to HIIN contacts soon
43
Qualaris Audit Tool Projects
Hand Hygiene
Culture of Safety Rounding
Sepsis
ReadmissionsCare Transitions
44
Qualaris mdash New Tools
Qualaris has new tools to assist users with coordinating successful improvement projects
Tracking project outcomes alongside process measures
Real-time dashboards inclusive of both outcomes and process measures
Documenting PDSAs
Click here to view the Qualaris improvement projects and outcomes demo
These tools require a short setup webinar session with Qualaris
Readmission Immersion Project participants should contact supportqualariscom
Use the Qualaris virtual chat support for next steps
45
LEAN Six Sigma Green Belt Project
Project launching mdashMarch 13 2018 through November 30 2018
Hospitals committed mdash20
Topic-focused
Patient throughput
ICU harm reduction
Errors in medication reconciliation
46
Capital Region Medical Center
Carroll County Memorial Hospital
Cass Regional Medical Center
Cox Medical Center
Fitzgibbon Hospital
Golden Valley Memorial Healthcare
Hannibal Regional Hospital
Lafayette Regional Health Center
Lake Regional Health System
Liberty Hospital
North Kansas City Hospital
Ozark Medical Center
Perry County Memorial Hospital
Saint Lukes Health System
Saint Lukes Hospital Kansas City
Scotland County Hospital
Southeast Missouri Hospital
St Marys Medical Center
Ste Genevieve County Memorial Hospital
Western Missouri Medical Center
NHSN Reporting Facilities
The January 23rd release of the NHSN 881 application will introduce an updated NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled in NHSN prior to December 2 2017 Facilities that enrolled in NHSN on or after December 2 2017 have already accessed this new Consent and will not need to accept it again if they have already done so
Primary Contacts or Facility Administrators should agree to this updated Consent form for each component by April 14th 2018 or risk losing access to NHSN
An alert will appear on all NHSN component home pages and primary contacts and facility administrators will receive an email notification
Additional information including Frequently Asked Questions and the updated NHSN purposes are available on CDCs NHSN website If you have any questions please send an email to NHSNcdcgov with the subject line ldquoNHSN Reconsentrdquo
47
NHSN Reporting Facilities
The NHSN team has published informational guidance on our website to assist users with completion of the updated NHSN Agreement to Participate and Consent A 5-minute video informs users of the new Consent purposes and the simple process for accepting the Consent electronically Furthermore a step-by-step guidance document provides detailed instructions and screen shots for what Facility Administrators and Primary Contacts can expect to see when they begin the re-consent process in the NHSN application A link to the video and the guidance document can both be found in the FAQs About NHSNrsquos Agreement to Participate and Consent
48
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
Solution Approach
Patients are risk stratified per the Modified Lace Tool
Focus is on high risk patients
Disease specific education with daily teach back method
Nursing Home Collaboration for high risk heart failure patients
Transition Care Nurses make visits to local nursing homes
SSM Home Connections visits to nursing homes in rural nursing homes
17
Solution Approach
Pharmacy admission and discharge medication reconciliation and disease specific education
Multi-disciplinary discharge planning on admission
Standing orderset used to place appropriate consults
Daily flash rounds to discuss discharge planning with a multidisciplinary team
18
Solution Approach
Daily meeting with SSM Home Health to review high risk patients
Daily assessment and report potential hazards for readmission to physician
Structured telephone program
Data collection to track leading indicators
Daily readmission report out for the GEMBA program
Weekly readmission RCA
19
Solution Approach
Weekly Core Team Meetings
Implemented on 21517 and ongoing currently
Root cause analysis on each readmission with action planinitiatives reviewedimplemented
Review status on all nursing home patientsvisits and address concerns and identify opportunities
Review at risk patients that are at home and address concerns and identify opportunities
Review leading and lagging indicators and address concerns and identify opportunities
Update on current corrective actions20
Test of ChangeRapid Experiment
Follow up appointment with physician within 5 business days to 100 in 2017
Improve patient actually attending the follow up appointment to 100 in 2017
Home health visits within 24 hours with front loading of visits 100 in 2017
Improve Medication Reconciliation on admission and discharge for all 5 diseases to 100 in 2017
21
Completion Plan
As of June 2017 scales can be provided for low income heart failure patients upon discharge
20172018 Development Projects
Robust palliative care program
Meal delivery program
Rescue Clinic
Improve physician engagement
Enhanced collaboration with LSS and Stonebridge (Quarterly meetings scheduled)
Palliative Care Program (Sub Team developing proposal)
Consider Code HF program (ED Implementation)
22
Confirmed State
Decrease HF readmissions from 202 in 2016 to 153 in 2017
Decrease COPD readmissions 198 in 2016 to 144 in 2017
Decrease PN readmissions from 122 in 2016 to 114 in 2017
Maintain AMI and CABG readmissions at better than the 90th percentile in 2017
23
Questions
24
Readmissions UpdateJosh Grotzinger
25
ICD-10 Readmission Update
October 2015 HIDI developed a GEM-mapped approach to the CMSYale risk-adjusted readmission models to accommodate ICD-9 and ICD-10 codes This action was taken prior to the availability of final ICD-910 compliant models from CMSYale to ensure continuity of readmission reporting for HIDI-participating hospitals
CMSYale released new ICD-910 compliant risk-adjusted readmission models with the release of the 2017 Hospital Compare data
26
CMSYale Documentation
CMSYale have validated their ICD-910 compliant models with documentation on QualityNet
Documentation on additionsexclusions from the cohort definitions are available through CMSYale on QualityNet
HIDI observed very modest levels of variation between the readmission models (HIDI GEM-mapped and CMSYale ICD-910 compliant)
27
Whatrsquos Coming after HIINJessica Stultz
28
Missouri Harm Dashboard
29
Missouri Harm Dashboard
MHA board initiative
Three harms
CAUTI
CLABSI
CDI
Reduce state rate by 10 percent
30
Missouri Harm Dashboard
All Missouri acute care hospitals
Excludes rehab psych LTAC womenrsquos childrens specialty veteransmilitary
Distributed to CEOs quarterly
2017 Q4 dashboard was distributed at district council last week
Targeted education materials to be sent at the leadership level
31
Missouri Harm Dashboard
Includes NHSN data only
Measuring improvement of rates
Most recent SIR will be shown on dashboard
Measuring improvement over state target
Calendar year 2016 baseline
Data will be pulled quarterly
2017 Q4 distributed March 2018
2018 Q1 will be distributed June 2018
32
33
HIIN Regional Boot Camps
To Increase Workersrsquo Safety
34
What to Expect
Attendees will be taught and have the opportunity to demonstrate
De-escalation management
Crisis intervention training to supplement the de-escalation techniques with a focus on mental health populations
Components of rape aggression defense training will be taught to offer realistic self-defense tactics and techniques
35
What to Expect
A holistic approach to reducing both the risk and anxiety surrounding violence in healthcare
Excellent supplement to existing safety programs already in place at your organizations
Offered at no cost to Missouri HRET-HIIN hospitals
Audience
front line staff in all care units (ED critical care and medical-surgical units)
safety and security personnel36
Locations and Times
Workplace safety
Blue Springs
ndash April 11 2018 at the Courtyard Marriott ndash Adams Pointe Conference Center
Springfield
ndash April 25 2018 at the Oasis Hotel and Convention Center
St Charles
ndash May 2 2018 at the Embassy Suites Hotel
Cape Girardeau
ndash May 9 2018 at the Drury Plaza Hotel Conference Center
37
HIIN Project Updates
38
Data Due Dates mdash HIIN Project Year 2
39
MHA ldquoZero Heroesrdquo Club
MHA congratulates the following HIIN-participating hospitals with the most zero harm measures reported These organizations have either achieved andor sustained a zero rate of harm and are in the top 10 percent of HIIN-participating hospitals Congratulations to the ldquoZero Herosrdquo for the month of September
Carroll County Memorial Hospital
Ellett Memorial Hospital
Harrison County Community Hospital
Iron County Medical Center
Osage Beach Center for Cognitive Disorders
Pike County Memorial Hospital
Southeast Health Center of Ripley County
Sullivan County Memorial Hospital
40
AHArsquos IT department investigated the emails and discovered they were generated by groups from Germany and Switzerland AHA recommends that your IT department block emails from these two countries unless you do business with them
SPAM Email from HEN or HIIN Finance mdash PLEASE IGNORE
If you receive an email asking you to pay your invoice via a link please ignore and permanently delete Do not click on the link in the email The email may come from different email addresses but is titled as HENHIIN Finance or HRET HIIN similar to what is pictured below
41
Hospital Leadership and Quality Assessment Tool
The tool measures board members C-suite executives and managementsupervisors on how well they are implementing evidence-based practices shown to support a culture of safety and high performance in clinical quality measures
No front-line staff survey component
Survey content
FAQ
42
HLQAT Survey
MHA is providing this complimentary opportunity for all HIIN hospitals to access and utilize this survey
Two options
Phase I mdash Completed
Phase II mdash April through August 2018
ndash Available to all HIIN hospitals mdash previous participation not
required
ndash Phase I hospitals may participate in phase II if desired
ndash Intent to participate materials will be sent to HIIN contacts soon
43
Qualaris Audit Tool Projects
Hand Hygiene
Culture of Safety Rounding
Sepsis
ReadmissionsCare Transitions
44
Qualaris mdash New Tools
Qualaris has new tools to assist users with coordinating successful improvement projects
Tracking project outcomes alongside process measures
Real-time dashboards inclusive of both outcomes and process measures
Documenting PDSAs
Click here to view the Qualaris improvement projects and outcomes demo
These tools require a short setup webinar session with Qualaris
Readmission Immersion Project participants should contact supportqualariscom
Use the Qualaris virtual chat support for next steps
45
LEAN Six Sigma Green Belt Project
Project launching mdashMarch 13 2018 through November 30 2018
Hospitals committed mdash20
Topic-focused
Patient throughput
ICU harm reduction
Errors in medication reconciliation
46
Capital Region Medical Center
Carroll County Memorial Hospital
Cass Regional Medical Center
Cox Medical Center
Fitzgibbon Hospital
Golden Valley Memorial Healthcare
Hannibal Regional Hospital
Lafayette Regional Health Center
Lake Regional Health System
Liberty Hospital
North Kansas City Hospital
Ozark Medical Center
Perry County Memorial Hospital
Saint Lukes Health System
Saint Lukes Hospital Kansas City
Scotland County Hospital
Southeast Missouri Hospital
St Marys Medical Center
Ste Genevieve County Memorial Hospital
Western Missouri Medical Center
NHSN Reporting Facilities
The January 23rd release of the NHSN 881 application will introduce an updated NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled in NHSN prior to December 2 2017 Facilities that enrolled in NHSN on or after December 2 2017 have already accessed this new Consent and will not need to accept it again if they have already done so
Primary Contacts or Facility Administrators should agree to this updated Consent form for each component by April 14th 2018 or risk losing access to NHSN
An alert will appear on all NHSN component home pages and primary contacts and facility administrators will receive an email notification
Additional information including Frequently Asked Questions and the updated NHSN purposes are available on CDCs NHSN website If you have any questions please send an email to NHSNcdcgov with the subject line ldquoNHSN Reconsentrdquo
47
NHSN Reporting Facilities
The NHSN team has published informational guidance on our website to assist users with completion of the updated NHSN Agreement to Participate and Consent A 5-minute video informs users of the new Consent purposes and the simple process for accepting the Consent electronically Furthermore a step-by-step guidance document provides detailed instructions and screen shots for what Facility Administrators and Primary Contacts can expect to see when they begin the re-consent process in the NHSN application A link to the video and the guidance document can both be found in the FAQs About NHSNrsquos Agreement to Participate and Consent
48
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
Solution Approach
Pharmacy admission and discharge medication reconciliation and disease specific education
Multi-disciplinary discharge planning on admission
Standing orderset used to place appropriate consults
Daily flash rounds to discuss discharge planning with a multidisciplinary team
18
Solution Approach
Daily meeting with SSM Home Health to review high risk patients
Daily assessment and report potential hazards for readmission to physician
Structured telephone program
Data collection to track leading indicators
Daily readmission report out for the GEMBA program
Weekly readmission RCA
19
Solution Approach
Weekly Core Team Meetings
Implemented on 21517 and ongoing currently
Root cause analysis on each readmission with action planinitiatives reviewedimplemented
Review status on all nursing home patientsvisits and address concerns and identify opportunities
Review at risk patients that are at home and address concerns and identify opportunities
Review leading and lagging indicators and address concerns and identify opportunities
Update on current corrective actions20
Test of ChangeRapid Experiment
Follow up appointment with physician within 5 business days to 100 in 2017
Improve patient actually attending the follow up appointment to 100 in 2017
Home health visits within 24 hours with front loading of visits 100 in 2017
Improve Medication Reconciliation on admission and discharge for all 5 diseases to 100 in 2017
21
Completion Plan
As of June 2017 scales can be provided for low income heart failure patients upon discharge
20172018 Development Projects
Robust palliative care program
Meal delivery program
Rescue Clinic
Improve physician engagement
Enhanced collaboration with LSS and Stonebridge (Quarterly meetings scheduled)
Palliative Care Program (Sub Team developing proposal)
Consider Code HF program (ED Implementation)
22
Confirmed State
Decrease HF readmissions from 202 in 2016 to 153 in 2017
Decrease COPD readmissions 198 in 2016 to 144 in 2017
Decrease PN readmissions from 122 in 2016 to 114 in 2017
Maintain AMI and CABG readmissions at better than the 90th percentile in 2017
23
Questions
24
Readmissions UpdateJosh Grotzinger
25
ICD-10 Readmission Update
October 2015 HIDI developed a GEM-mapped approach to the CMSYale risk-adjusted readmission models to accommodate ICD-9 and ICD-10 codes This action was taken prior to the availability of final ICD-910 compliant models from CMSYale to ensure continuity of readmission reporting for HIDI-participating hospitals
CMSYale released new ICD-910 compliant risk-adjusted readmission models with the release of the 2017 Hospital Compare data
26
CMSYale Documentation
CMSYale have validated their ICD-910 compliant models with documentation on QualityNet
Documentation on additionsexclusions from the cohort definitions are available through CMSYale on QualityNet
HIDI observed very modest levels of variation between the readmission models (HIDI GEM-mapped and CMSYale ICD-910 compliant)
27
Whatrsquos Coming after HIINJessica Stultz
28
Missouri Harm Dashboard
29
Missouri Harm Dashboard
MHA board initiative
Three harms
CAUTI
CLABSI
CDI
Reduce state rate by 10 percent
30
Missouri Harm Dashboard
All Missouri acute care hospitals
Excludes rehab psych LTAC womenrsquos childrens specialty veteransmilitary
Distributed to CEOs quarterly
2017 Q4 dashboard was distributed at district council last week
Targeted education materials to be sent at the leadership level
31
Missouri Harm Dashboard
Includes NHSN data only
Measuring improvement of rates
Most recent SIR will be shown on dashboard
Measuring improvement over state target
Calendar year 2016 baseline
Data will be pulled quarterly
2017 Q4 distributed March 2018
2018 Q1 will be distributed June 2018
32
33
HIIN Regional Boot Camps
To Increase Workersrsquo Safety
34
What to Expect
Attendees will be taught and have the opportunity to demonstrate
De-escalation management
Crisis intervention training to supplement the de-escalation techniques with a focus on mental health populations
Components of rape aggression defense training will be taught to offer realistic self-defense tactics and techniques
35
What to Expect
A holistic approach to reducing both the risk and anxiety surrounding violence in healthcare
Excellent supplement to existing safety programs already in place at your organizations
Offered at no cost to Missouri HRET-HIIN hospitals
Audience
front line staff in all care units (ED critical care and medical-surgical units)
safety and security personnel36
Locations and Times
Workplace safety
Blue Springs
ndash April 11 2018 at the Courtyard Marriott ndash Adams Pointe Conference Center
Springfield
ndash April 25 2018 at the Oasis Hotel and Convention Center
St Charles
ndash May 2 2018 at the Embassy Suites Hotel
Cape Girardeau
ndash May 9 2018 at the Drury Plaza Hotel Conference Center
37
HIIN Project Updates
38
Data Due Dates mdash HIIN Project Year 2
39
MHA ldquoZero Heroesrdquo Club
MHA congratulates the following HIIN-participating hospitals with the most zero harm measures reported These organizations have either achieved andor sustained a zero rate of harm and are in the top 10 percent of HIIN-participating hospitals Congratulations to the ldquoZero Herosrdquo for the month of September
Carroll County Memorial Hospital
Ellett Memorial Hospital
Harrison County Community Hospital
Iron County Medical Center
Osage Beach Center for Cognitive Disorders
Pike County Memorial Hospital
Southeast Health Center of Ripley County
Sullivan County Memorial Hospital
40
AHArsquos IT department investigated the emails and discovered they were generated by groups from Germany and Switzerland AHA recommends that your IT department block emails from these two countries unless you do business with them
SPAM Email from HEN or HIIN Finance mdash PLEASE IGNORE
If you receive an email asking you to pay your invoice via a link please ignore and permanently delete Do not click on the link in the email The email may come from different email addresses but is titled as HENHIIN Finance or HRET HIIN similar to what is pictured below
41
Hospital Leadership and Quality Assessment Tool
The tool measures board members C-suite executives and managementsupervisors on how well they are implementing evidence-based practices shown to support a culture of safety and high performance in clinical quality measures
No front-line staff survey component
Survey content
FAQ
42
HLQAT Survey
MHA is providing this complimentary opportunity for all HIIN hospitals to access and utilize this survey
Two options
Phase I mdash Completed
Phase II mdash April through August 2018
ndash Available to all HIIN hospitals mdash previous participation not
required
ndash Phase I hospitals may participate in phase II if desired
ndash Intent to participate materials will be sent to HIIN contacts soon
43
Qualaris Audit Tool Projects
Hand Hygiene
Culture of Safety Rounding
Sepsis
ReadmissionsCare Transitions
44
Qualaris mdash New Tools
Qualaris has new tools to assist users with coordinating successful improvement projects
Tracking project outcomes alongside process measures
Real-time dashboards inclusive of both outcomes and process measures
Documenting PDSAs
Click here to view the Qualaris improvement projects and outcomes demo
These tools require a short setup webinar session with Qualaris
Readmission Immersion Project participants should contact supportqualariscom
Use the Qualaris virtual chat support for next steps
45
LEAN Six Sigma Green Belt Project
Project launching mdashMarch 13 2018 through November 30 2018
Hospitals committed mdash20
Topic-focused
Patient throughput
ICU harm reduction
Errors in medication reconciliation
46
Capital Region Medical Center
Carroll County Memorial Hospital
Cass Regional Medical Center
Cox Medical Center
Fitzgibbon Hospital
Golden Valley Memorial Healthcare
Hannibal Regional Hospital
Lafayette Regional Health Center
Lake Regional Health System
Liberty Hospital
North Kansas City Hospital
Ozark Medical Center
Perry County Memorial Hospital
Saint Lukes Health System
Saint Lukes Hospital Kansas City
Scotland County Hospital
Southeast Missouri Hospital
St Marys Medical Center
Ste Genevieve County Memorial Hospital
Western Missouri Medical Center
NHSN Reporting Facilities
The January 23rd release of the NHSN 881 application will introduce an updated NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled in NHSN prior to December 2 2017 Facilities that enrolled in NHSN on or after December 2 2017 have already accessed this new Consent and will not need to accept it again if they have already done so
Primary Contacts or Facility Administrators should agree to this updated Consent form for each component by April 14th 2018 or risk losing access to NHSN
An alert will appear on all NHSN component home pages and primary contacts and facility administrators will receive an email notification
Additional information including Frequently Asked Questions and the updated NHSN purposes are available on CDCs NHSN website If you have any questions please send an email to NHSNcdcgov with the subject line ldquoNHSN Reconsentrdquo
47
NHSN Reporting Facilities
The NHSN team has published informational guidance on our website to assist users with completion of the updated NHSN Agreement to Participate and Consent A 5-minute video informs users of the new Consent purposes and the simple process for accepting the Consent electronically Furthermore a step-by-step guidance document provides detailed instructions and screen shots for what Facility Administrators and Primary Contacts can expect to see when they begin the re-consent process in the NHSN application A link to the video and the guidance document can both be found in the FAQs About NHSNrsquos Agreement to Participate and Consent
48
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
Solution Approach
Daily meeting with SSM Home Health to review high risk patients
Daily assessment and report potential hazards for readmission to physician
Structured telephone program
Data collection to track leading indicators
Daily readmission report out for the GEMBA program
Weekly readmission RCA
19
Solution Approach
Weekly Core Team Meetings
Implemented on 21517 and ongoing currently
Root cause analysis on each readmission with action planinitiatives reviewedimplemented
Review status on all nursing home patientsvisits and address concerns and identify opportunities
Review at risk patients that are at home and address concerns and identify opportunities
Review leading and lagging indicators and address concerns and identify opportunities
Update on current corrective actions20
Test of ChangeRapid Experiment
Follow up appointment with physician within 5 business days to 100 in 2017
Improve patient actually attending the follow up appointment to 100 in 2017
Home health visits within 24 hours with front loading of visits 100 in 2017
Improve Medication Reconciliation on admission and discharge for all 5 diseases to 100 in 2017
21
Completion Plan
As of June 2017 scales can be provided for low income heart failure patients upon discharge
20172018 Development Projects
Robust palliative care program
Meal delivery program
Rescue Clinic
Improve physician engagement
Enhanced collaboration with LSS and Stonebridge (Quarterly meetings scheduled)
Palliative Care Program (Sub Team developing proposal)
Consider Code HF program (ED Implementation)
22
Confirmed State
Decrease HF readmissions from 202 in 2016 to 153 in 2017
Decrease COPD readmissions 198 in 2016 to 144 in 2017
Decrease PN readmissions from 122 in 2016 to 114 in 2017
Maintain AMI and CABG readmissions at better than the 90th percentile in 2017
23
Questions
24
Readmissions UpdateJosh Grotzinger
25
ICD-10 Readmission Update
October 2015 HIDI developed a GEM-mapped approach to the CMSYale risk-adjusted readmission models to accommodate ICD-9 and ICD-10 codes This action was taken prior to the availability of final ICD-910 compliant models from CMSYale to ensure continuity of readmission reporting for HIDI-participating hospitals
CMSYale released new ICD-910 compliant risk-adjusted readmission models with the release of the 2017 Hospital Compare data
26
CMSYale Documentation
CMSYale have validated their ICD-910 compliant models with documentation on QualityNet
Documentation on additionsexclusions from the cohort definitions are available through CMSYale on QualityNet
HIDI observed very modest levels of variation between the readmission models (HIDI GEM-mapped and CMSYale ICD-910 compliant)
27
Whatrsquos Coming after HIINJessica Stultz
28
Missouri Harm Dashboard
29
Missouri Harm Dashboard
MHA board initiative
Three harms
CAUTI
CLABSI
CDI
Reduce state rate by 10 percent
30
Missouri Harm Dashboard
All Missouri acute care hospitals
Excludes rehab psych LTAC womenrsquos childrens specialty veteransmilitary
Distributed to CEOs quarterly
2017 Q4 dashboard was distributed at district council last week
Targeted education materials to be sent at the leadership level
31
Missouri Harm Dashboard
Includes NHSN data only
Measuring improvement of rates
Most recent SIR will be shown on dashboard
Measuring improvement over state target
Calendar year 2016 baseline
Data will be pulled quarterly
2017 Q4 distributed March 2018
2018 Q1 will be distributed June 2018
32
33
HIIN Regional Boot Camps
To Increase Workersrsquo Safety
34
What to Expect
Attendees will be taught and have the opportunity to demonstrate
De-escalation management
Crisis intervention training to supplement the de-escalation techniques with a focus on mental health populations
Components of rape aggression defense training will be taught to offer realistic self-defense tactics and techniques
35
What to Expect
A holistic approach to reducing both the risk and anxiety surrounding violence in healthcare
Excellent supplement to existing safety programs already in place at your organizations
Offered at no cost to Missouri HRET-HIIN hospitals
Audience
front line staff in all care units (ED critical care and medical-surgical units)
safety and security personnel36
Locations and Times
Workplace safety
Blue Springs
ndash April 11 2018 at the Courtyard Marriott ndash Adams Pointe Conference Center
Springfield
ndash April 25 2018 at the Oasis Hotel and Convention Center
St Charles
ndash May 2 2018 at the Embassy Suites Hotel
Cape Girardeau
ndash May 9 2018 at the Drury Plaza Hotel Conference Center
37
HIIN Project Updates
38
Data Due Dates mdash HIIN Project Year 2
39
MHA ldquoZero Heroesrdquo Club
MHA congratulates the following HIIN-participating hospitals with the most zero harm measures reported These organizations have either achieved andor sustained a zero rate of harm and are in the top 10 percent of HIIN-participating hospitals Congratulations to the ldquoZero Herosrdquo for the month of September
Carroll County Memorial Hospital
Ellett Memorial Hospital
Harrison County Community Hospital
Iron County Medical Center
Osage Beach Center for Cognitive Disorders
Pike County Memorial Hospital
Southeast Health Center of Ripley County
Sullivan County Memorial Hospital
40
AHArsquos IT department investigated the emails and discovered they were generated by groups from Germany and Switzerland AHA recommends that your IT department block emails from these two countries unless you do business with them
SPAM Email from HEN or HIIN Finance mdash PLEASE IGNORE
If you receive an email asking you to pay your invoice via a link please ignore and permanently delete Do not click on the link in the email The email may come from different email addresses but is titled as HENHIIN Finance or HRET HIIN similar to what is pictured below
41
Hospital Leadership and Quality Assessment Tool
The tool measures board members C-suite executives and managementsupervisors on how well they are implementing evidence-based practices shown to support a culture of safety and high performance in clinical quality measures
No front-line staff survey component
Survey content
FAQ
42
HLQAT Survey
MHA is providing this complimentary opportunity for all HIIN hospitals to access and utilize this survey
Two options
Phase I mdash Completed
Phase II mdash April through August 2018
ndash Available to all HIIN hospitals mdash previous participation not
required
ndash Phase I hospitals may participate in phase II if desired
ndash Intent to participate materials will be sent to HIIN contacts soon
43
Qualaris Audit Tool Projects
Hand Hygiene
Culture of Safety Rounding
Sepsis
ReadmissionsCare Transitions
44
Qualaris mdash New Tools
Qualaris has new tools to assist users with coordinating successful improvement projects
Tracking project outcomes alongside process measures
Real-time dashboards inclusive of both outcomes and process measures
Documenting PDSAs
Click here to view the Qualaris improvement projects and outcomes demo
These tools require a short setup webinar session with Qualaris
Readmission Immersion Project participants should contact supportqualariscom
Use the Qualaris virtual chat support for next steps
45
LEAN Six Sigma Green Belt Project
Project launching mdashMarch 13 2018 through November 30 2018
Hospitals committed mdash20
Topic-focused
Patient throughput
ICU harm reduction
Errors in medication reconciliation
46
Capital Region Medical Center
Carroll County Memorial Hospital
Cass Regional Medical Center
Cox Medical Center
Fitzgibbon Hospital
Golden Valley Memorial Healthcare
Hannibal Regional Hospital
Lafayette Regional Health Center
Lake Regional Health System
Liberty Hospital
North Kansas City Hospital
Ozark Medical Center
Perry County Memorial Hospital
Saint Lukes Health System
Saint Lukes Hospital Kansas City
Scotland County Hospital
Southeast Missouri Hospital
St Marys Medical Center
Ste Genevieve County Memorial Hospital
Western Missouri Medical Center
NHSN Reporting Facilities
The January 23rd release of the NHSN 881 application will introduce an updated NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled in NHSN prior to December 2 2017 Facilities that enrolled in NHSN on or after December 2 2017 have already accessed this new Consent and will not need to accept it again if they have already done so
Primary Contacts or Facility Administrators should agree to this updated Consent form for each component by April 14th 2018 or risk losing access to NHSN
An alert will appear on all NHSN component home pages and primary contacts and facility administrators will receive an email notification
Additional information including Frequently Asked Questions and the updated NHSN purposes are available on CDCs NHSN website If you have any questions please send an email to NHSNcdcgov with the subject line ldquoNHSN Reconsentrdquo
47
NHSN Reporting Facilities
The NHSN team has published informational guidance on our website to assist users with completion of the updated NHSN Agreement to Participate and Consent A 5-minute video informs users of the new Consent purposes and the simple process for accepting the Consent electronically Furthermore a step-by-step guidance document provides detailed instructions and screen shots for what Facility Administrators and Primary Contacts can expect to see when they begin the re-consent process in the NHSN application A link to the video and the guidance document can both be found in the FAQs About NHSNrsquos Agreement to Participate and Consent
48
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
Solution Approach
Weekly Core Team Meetings
Implemented on 21517 and ongoing currently
Root cause analysis on each readmission with action planinitiatives reviewedimplemented
Review status on all nursing home patientsvisits and address concerns and identify opportunities
Review at risk patients that are at home and address concerns and identify opportunities
Review leading and lagging indicators and address concerns and identify opportunities
Update on current corrective actions20
Test of ChangeRapid Experiment
Follow up appointment with physician within 5 business days to 100 in 2017
Improve patient actually attending the follow up appointment to 100 in 2017
Home health visits within 24 hours with front loading of visits 100 in 2017
Improve Medication Reconciliation on admission and discharge for all 5 diseases to 100 in 2017
21
Completion Plan
As of June 2017 scales can be provided for low income heart failure patients upon discharge
20172018 Development Projects
Robust palliative care program
Meal delivery program
Rescue Clinic
Improve physician engagement
Enhanced collaboration with LSS and Stonebridge (Quarterly meetings scheduled)
Palliative Care Program (Sub Team developing proposal)
Consider Code HF program (ED Implementation)
22
Confirmed State
Decrease HF readmissions from 202 in 2016 to 153 in 2017
Decrease COPD readmissions 198 in 2016 to 144 in 2017
Decrease PN readmissions from 122 in 2016 to 114 in 2017
Maintain AMI and CABG readmissions at better than the 90th percentile in 2017
23
Questions
24
Readmissions UpdateJosh Grotzinger
25
ICD-10 Readmission Update
October 2015 HIDI developed a GEM-mapped approach to the CMSYale risk-adjusted readmission models to accommodate ICD-9 and ICD-10 codes This action was taken prior to the availability of final ICD-910 compliant models from CMSYale to ensure continuity of readmission reporting for HIDI-participating hospitals
CMSYale released new ICD-910 compliant risk-adjusted readmission models with the release of the 2017 Hospital Compare data
26
CMSYale Documentation
CMSYale have validated their ICD-910 compliant models with documentation on QualityNet
Documentation on additionsexclusions from the cohort definitions are available through CMSYale on QualityNet
HIDI observed very modest levels of variation between the readmission models (HIDI GEM-mapped and CMSYale ICD-910 compliant)
27
Whatrsquos Coming after HIINJessica Stultz
28
Missouri Harm Dashboard
29
Missouri Harm Dashboard
MHA board initiative
Three harms
CAUTI
CLABSI
CDI
Reduce state rate by 10 percent
30
Missouri Harm Dashboard
All Missouri acute care hospitals
Excludes rehab psych LTAC womenrsquos childrens specialty veteransmilitary
Distributed to CEOs quarterly
2017 Q4 dashboard was distributed at district council last week
Targeted education materials to be sent at the leadership level
31
Missouri Harm Dashboard
Includes NHSN data only
Measuring improvement of rates
Most recent SIR will be shown on dashboard
Measuring improvement over state target
Calendar year 2016 baseline
Data will be pulled quarterly
2017 Q4 distributed March 2018
2018 Q1 will be distributed June 2018
32
33
HIIN Regional Boot Camps
To Increase Workersrsquo Safety
34
What to Expect
Attendees will be taught and have the opportunity to demonstrate
De-escalation management
Crisis intervention training to supplement the de-escalation techniques with a focus on mental health populations
Components of rape aggression defense training will be taught to offer realistic self-defense tactics and techniques
35
What to Expect
A holistic approach to reducing both the risk and anxiety surrounding violence in healthcare
Excellent supplement to existing safety programs already in place at your organizations
Offered at no cost to Missouri HRET-HIIN hospitals
Audience
front line staff in all care units (ED critical care and medical-surgical units)
safety and security personnel36
Locations and Times
Workplace safety
Blue Springs
ndash April 11 2018 at the Courtyard Marriott ndash Adams Pointe Conference Center
Springfield
ndash April 25 2018 at the Oasis Hotel and Convention Center
St Charles
ndash May 2 2018 at the Embassy Suites Hotel
Cape Girardeau
ndash May 9 2018 at the Drury Plaza Hotel Conference Center
37
HIIN Project Updates
38
Data Due Dates mdash HIIN Project Year 2
39
MHA ldquoZero Heroesrdquo Club
MHA congratulates the following HIIN-participating hospitals with the most zero harm measures reported These organizations have either achieved andor sustained a zero rate of harm and are in the top 10 percent of HIIN-participating hospitals Congratulations to the ldquoZero Herosrdquo for the month of September
Carroll County Memorial Hospital
Ellett Memorial Hospital
Harrison County Community Hospital
Iron County Medical Center
Osage Beach Center for Cognitive Disorders
Pike County Memorial Hospital
Southeast Health Center of Ripley County
Sullivan County Memorial Hospital
40
AHArsquos IT department investigated the emails and discovered they were generated by groups from Germany and Switzerland AHA recommends that your IT department block emails from these two countries unless you do business with them
SPAM Email from HEN or HIIN Finance mdash PLEASE IGNORE
If you receive an email asking you to pay your invoice via a link please ignore and permanently delete Do not click on the link in the email The email may come from different email addresses but is titled as HENHIIN Finance or HRET HIIN similar to what is pictured below
41
Hospital Leadership and Quality Assessment Tool
The tool measures board members C-suite executives and managementsupervisors on how well they are implementing evidence-based practices shown to support a culture of safety and high performance in clinical quality measures
No front-line staff survey component
Survey content
FAQ
42
HLQAT Survey
MHA is providing this complimentary opportunity for all HIIN hospitals to access and utilize this survey
Two options
Phase I mdash Completed
Phase II mdash April through August 2018
ndash Available to all HIIN hospitals mdash previous participation not
required
ndash Phase I hospitals may participate in phase II if desired
ndash Intent to participate materials will be sent to HIIN contacts soon
43
Qualaris Audit Tool Projects
Hand Hygiene
Culture of Safety Rounding
Sepsis
ReadmissionsCare Transitions
44
Qualaris mdash New Tools
Qualaris has new tools to assist users with coordinating successful improvement projects
Tracking project outcomes alongside process measures
Real-time dashboards inclusive of both outcomes and process measures
Documenting PDSAs
Click here to view the Qualaris improvement projects and outcomes demo
These tools require a short setup webinar session with Qualaris
Readmission Immersion Project participants should contact supportqualariscom
Use the Qualaris virtual chat support for next steps
45
LEAN Six Sigma Green Belt Project
Project launching mdashMarch 13 2018 through November 30 2018
Hospitals committed mdash20
Topic-focused
Patient throughput
ICU harm reduction
Errors in medication reconciliation
46
Capital Region Medical Center
Carroll County Memorial Hospital
Cass Regional Medical Center
Cox Medical Center
Fitzgibbon Hospital
Golden Valley Memorial Healthcare
Hannibal Regional Hospital
Lafayette Regional Health Center
Lake Regional Health System
Liberty Hospital
North Kansas City Hospital
Ozark Medical Center
Perry County Memorial Hospital
Saint Lukes Health System
Saint Lukes Hospital Kansas City
Scotland County Hospital
Southeast Missouri Hospital
St Marys Medical Center
Ste Genevieve County Memorial Hospital
Western Missouri Medical Center
NHSN Reporting Facilities
The January 23rd release of the NHSN 881 application will introduce an updated NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled in NHSN prior to December 2 2017 Facilities that enrolled in NHSN on or after December 2 2017 have already accessed this new Consent and will not need to accept it again if they have already done so
Primary Contacts or Facility Administrators should agree to this updated Consent form for each component by April 14th 2018 or risk losing access to NHSN
An alert will appear on all NHSN component home pages and primary contacts and facility administrators will receive an email notification
Additional information including Frequently Asked Questions and the updated NHSN purposes are available on CDCs NHSN website If you have any questions please send an email to NHSNcdcgov with the subject line ldquoNHSN Reconsentrdquo
47
NHSN Reporting Facilities
The NHSN team has published informational guidance on our website to assist users with completion of the updated NHSN Agreement to Participate and Consent A 5-minute video informs users of the new Consent purposes and the simple process for accepting the Consent electronically Furthermore a step-by-step guidance document provides detailed instructions and screen shots for what Facility Administrators and Primary Contacts can expect to see when they begin the re-consent process in the NHSN application A link to the video and the guidance document can both be found in the FAQs About NHSNrsquos Agreement to Participate and Consent
48
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
Test of ChangeRapid Experiment
Follow up appointment with physician within 5 business days to 100 in 2017
Improve patient actually attending the follow up appointment to 100 in 2017
Home health visits within 24 hours with front loading of visits 100 in 2017
Improve Medication Reconciliation on admission and discharge for all 5 diseases to 100 in 2017
21
Completion Plan
As of June 2017 scales can be provided for low income heart failure patients upon discharge
20172018 Development Projects
Robust palliative care program
Meal delivery program
Rescue Clinic
Improve physician engagement
Enhanced collaboration with LSS and Stonebridge (Quarterly meetings scheduled)
Palliative Care Program (Sub Team developing proposal)
Consider Code HF program (ED Implementation)
22
Confirmed State
Decrease HF readmissions from 202 in 2016 to 153 in 2017
Decrease COPD readmissions 198 in 2016 to 144 in 2017
Decrease PN readmissions from 122 in 2016 to 114 in 2017
Maintain AMI and CABG readmissions at better than the 90th percentile in 2017
23
Questions
24
Readmissions UpdateJosh Grotzinger
25
ICD-10 Readmission Update
October 2015 HIDI developed a GEM-mapped approach to the CMSYale risk-adjusted readmission models to accommodate ICD-9 and ICD-10 codes This action was taken prior to the availability of final ICD-910 compliant models from CMSYale to ensure continuity of readmission reporting for HIDI-participating hospitals
CMSYale released new ICD-910 compliant risk-adjusted readmission models with the release of the 2017 Hospital Compare data
26
CMSYale Documentation
CMSYale have validated their ICD-910 compliant models with documentation on QualityNet
Documentation on additionsexclusions from the cohort definitions are available through CMSYale on QualityNet
HIDI observed very modest levels of variation between the readmission models (HIDI GEM-mapped and CMSYale ICD-910 compliant)
27
Whatrsquos Coming after HIINJessica Stultz
28
Missouri Harm Dashboard
29
Missouri Harm Dashboard
MHA board initiative
Three harms
CAUTI
CLABSI
CDI
Reduce state rate by 10 percent
30
Missouri Harm Dashboard
All Missouri acute care hospitals
Excludes rehab psych LTAC womenrsquos childrens specialty veteransmilitary
Distributed to CEOs quarterly
2017 Q4 dashboard was distributed at district council last week
Targeted education materials to be sent at the leadership level
31
Missouri Harm Dashboard
Includes NHSN data only
Measuring improvement of rates
Most recent SIR will be shown on dashboard
Measuring improvement over state target
Calendar year 2016 baseline
Data will be pulled quarterly
2017 Q4 distributed March 2018
2018 Q1 will be distributed June 2018
32
33
HIIN Regional Boot Camps
To Increase Workersrsquo Safety
34
What to Expect
Attendees will be taught and have the opportunity to demonstrate
De-escalation management
Crisis intervention training to supplement the de-escalation techniques with a focus on mental health populations
Components of rape aggression defense training will be taught to offer realistic self-defense tactics and techniques
35
What to Expect
A holistic approach to reducing both the risk and anxiety surrounding violence in healthcare
Excellent supplement to existing safety programs already in place at your organizations
Offered at no cost to Missouri HRET-HIIN hospitals
Audience
front line staff in all care units (ED critical care and medical-surgical units)
safety and security personnel36
Locations and Times
Workplace safety
Blue Springs
ndash April 11 2018 at the Courtyard Marriott ndash Adams Pointe Conference Center
Springfield
ndash April 25 2018 at the Oasis Hotel and Convention Center
St Charles
ndash May 2 2018 at the Embassy Suites Hotel
Cape Girardeau
ndash May 9 2018 at the Drury Plaza Hotel Conference Center
37
HIIN Project Updates
38
Data Due Dates mdash HIIN Project Year 2
39
MHA ldquoZero Heroesrdquo Club
MHA congratulates the following HIIN-participating hospitals with the most zero harm measures reported These organizations have either achieved andor sustained a zero rate of harm and are in the top 10 percent of HIIN-participating hospitals Congratulations to the ldquoZero Herosrdquo for the month of September
Carroll County Memorial Hospital
Ellett Memorial Hospital
Harrison County Community Hospital
Iron County Medical Center
Osage Beach Center for Cognitive Disorders
Pike County Memorial Hospital
Southeast Health Center of Ripley County
Sullivan County Memorial Hospital
40
AHArsquos IT department investigated the emails and discovered they were generated by groups from Germany and Switzerland AHA recommends that your IT department block emails from these two countries unless you do business with them
SPAM Email from HEN or HIIN Finance mdash PLEASE IGNORE
If you receive an email asking you to pay your invoice via a link please ignore and permanently delete Do not click on the link in the email The email may come from different email addresses but is titled as HENHIIN Finance or HRET HIIN similar to what is pictured below
41
Hospital Leadership and Quality Assessment Tool
The tool measures board members C-suite executives and managementsupervisors on how well they are implementing evidence-based practices shown to support a culture of safety and high performance in clinical quality measures
No front-line staff survey component
Survey content
FAQ
42
HLQAT Survey
MHA is providing this complimentary opportunity for all HIIN hospitals to access and utilize this survey
Two options
Phase I mdash Completed
Phase II mdash April through August 2018
ndash Available to all HIIN hospitals mdash previous participation not
required
ndash Phase I hospitals may participate in phase II if desired
ndash Intent to participate materials will be sent to HIIN contacts soon
43
Qualaris Audit Tool Projects
Hand Hygiene
Culture of Safety Rounding
Sepsis
ReadmissionsCare Transitions
44
Qualaris mdash New Tools
Qualaris has new tools to assist users with coordinating successful improvement projects
Tracking project outcomes alongside process measures
Real-time dashboards inclusive of both outcomes and process measures
Documenting PDSAs
Click here to view the Qualaris improvement projects and outcomes demo
These tools require a short setup webinar session with Qualaris
Readmission Immersion Project participants should contact supportqualariscom
Use the Qualaris virtual chat support for next steps
45
LEAN Six Sigma Green Belt Project
Project launching mdashMarch 13 2018 through November 30 2018
Hospitals committed mdash20
Topic-focused
Patient throughput
ICU harm reduction
Errors in medication reconciliation
46
Capital Region Medical Center
Carroll County Memorial Hospital
Cass Regional Medical Center
Cox Medical Center
Fitzgibbon Hospital
Golden Valley Memorial Healthcare
Hannibal Regional Hospital
Lafayette Regional Health Center
Lake Regional Health System
Liberty Hospital
North Kansas City Hospital
Ozark Medical Center
Perry County Memorial Hospital
Saint Lukes Health System
Saint Lukes Hospital Kansas City
Scotland County Hospital
Southeast Missouri Hospital
St Marys Medical Center
Ste Genevieve County Memorial Hospital
Western Missouri Medical Center
NHSN Reporting Facilities
The January 23rd release of the NHSN 881 application will introduce an updated NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled in NHSN prior to December 2 2017 Facilities that enrolled in NHSN on or after December 2 2017 have already accessed this new Consent and will not need to accept it again if they have already done so
Primary Contacts or Facility Administrators should agree to this updated Consent form for each component by April 14th 2018 or risk losing access to NHSN
An alert will appear on all NHSN component home pages and primary contacts and facility administrators will receive an email notification
Additional information including Frequently Asked Questions and the updated NHSN purposes are available on CDCs NHSN website If you have any questions please send an email to NHSNcdcgov with the subject line ldquoNHSN Reconsentrdquo
47
NHSN Reporting Facilities
The NHSN team has published informational guidance on our website to assist users with completion of the updated NHSN Agreement to Participate and Consent A 5-minute video informs users of the new Consent purposes and the simple process for accepting the Consent electronically Furthermore a step-by-step guidance document provides detailed instructions and screen shots for what Facility Administrators and Primary Contacts can expect to see when they begin the re-consent process in the NHSN application A link to the video and the guidance document can both be found in the FAQs About NHSNrsquos Agreement to Participate and Consent
48
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
Completion Plan
As of June 2017 scales can be provided for low income heart failure patients upon discharge
20172018 Development Projects
Robust palliative care program
Meal delivery program
Rescue Clinic
Improve physician engagement
Enhanced collaboration with LSS and Stonebridge (Quarterly meetings scheduled)
Palliative Care Program (Sub Team developing proposal)
Consider Code HF program (ED Implementation)
22
Confirmed State
Decrease HF readmissions from 202 in 2016 to 153 in 2017
Decrease COPD readmissions 198 in 2016 to 144 in 2017
Decrease PN readmissions from 122 in 2016 to 114 in 2017
Maintain AMI and CABG readmissions at better than the 90th percentile in 2017
23
Questions
24
Readmissions UpdateJosh Grotzinger
25
ICD-10 Readmission Update
October 2015 HIDI developed a GEM-mapped approach to the CMSYale risk-adjusted readmission models to accommodate ICD-9 and ICD-10 codes This action was taken prior to the availability of final ICD-910 compliant models from CMSYale to ensure continuity of readmission reporting for HIDI-participating hospitals
CMSYale released new ICD-910 compliant risk-adjusted readmission models with the release of the 2017 Hospital Compare data
26
CMSYale Documentation
CMSYale have validated their ICD-910 compliant models with documentation on QualityNet
Documentation on additionsexclusions from the cohort definitions are available through CMSYale on QualityNet
HIDI observed very modest levels of variation between the readmission models (HIDI GEM-mapped and CMSYale ICD-910 compliant)
27
Whatrsquos Coming after HIINJessica Stultz
28
Missouri Harm Dashboard
29
Missouri Harm Dashboard
MHA board initiative
Three harms
CAUTI
CLABSI
CDI
Reduce state rate by 10 percent
30
Missouri Harm Dashboard
All Missouri acute care hospitals
Excludes rehab psych LTAC womenrsquos childrens specialty veteransmilitary
Distributed to CEOs quarterly
2017 Q4 dashboard was distributed at district council last week
Targeted education materials to be sent at the leadership level
31
Missouri Harm Dashboard
Includes NHSN data only
Measuring improvement of rates
Most recent SIR will be shown on dashboard
Measuring improvement over state target
Calendar year 2016 baseline
Data will be pulled quarterly
2017 Q4 distributed March 2018
2018 Q1 will be distributed June 2018
32
33
HIIN Regional Boot Camps
To Increase Workersrsquo Safety
34
What to Expect
Attendees will be taught and have the opportunity to demonstrate
De-escalation management
Crisis intervention training to supplement the de-escalation techniques with a focus on mental health populations
Components of rape aggression defense training will be taught to offer realistic self-defense tactics and techniques
35
What to Expect
A holistic approach to reducing both the risk and anxiety surrounding violence in healthcare
Excellent supplement to existing safety programs already in place at your organizations
Offered at no cost to Missouri HRET-HIIN hospitals
Audience
front line staff in all care units (ED critical care and medical-surgical units)
safety and security personnel36
Locations and Times
Workplace safety
Blue Springs
ndash April 11 2018 at the Courtyard Marriott ndash Adams Pointe Conference Center
Springfield
ndash April 25 2018 at the Oasis Hotel and Convention Center
St Charles
ndash May 2 2018 at the Embassy Suites Hotel
Cape Girardeau
ndash May 9 2018 at the Drury Plaza Hotel Conference Center
37
HIIN Project Updates
38
Data Due Dates mdash HIIN Project Year 2
39
MHA ldquoZero Heroesrdquo Club
MHA congratulates the following HIIN-participating hospitals with the most zero harm measures reported These organizations have either achieved andor sustained a zero rate of harm and are in the top 10 percent of HIIN-participating hospitals Congratulations to the ldquoZero Herosrdquo for the month of September
Carroll County Memorial Hospital
Ellett Memorial Hospital
Harrison County Community Hospital
Iron County Medical Center
Osage Beach Center for Cognitive Disorders
Pike County Memorial Hospital
Southeast Health Center of Ripley County
Sullivan County Memorial Hospital
40
AHArsquos IT department investigated the emails and discovered they were generated by groups from Germany and Switzerland AHA recommends that your IT department block emails from these two countries unless you do business with them
SPAM Email from HEN or HIIN Finance mdash PLEASE IGNORE
If you receive an email asking you to pay your invoice via a link please ignore and permanently delete Do not click on the link in the email The email may come from different email addresses but is titled as HENHIIN Finance or HRET HIIN similar to what is pictured below
41
Hospital Leadership and Quality Assessment Tool
The tool measures board members C-suite executives and managementsupervisors on how well they are implementing evidence-based practices shown to support a culture of safety and high performance in clinical quality measures
No front-line staff survey component
Survey content
FAQ
42
HLQAT Survey
MHA is providing this complimentary opportunity for all HIIN hospitals to access and utilize this survey
Two options
Phase I mdash Completed
Phase II mdash April through August 2018
ndash Available to all HIIN hospitals mdash previous participation not
required
ndash Phase I hospitals may participate in phase II if desired
ndash Intent to participate materials will be sent to HIIN contacts soon
43
Qualaris Audit Tool Projects
Hand Hygiene
Culture of Safety Rounding
Sepsis
ReadmissionsCare Transitions
44
Qualaris mdash New Tools
Qualaris has new tools to assist users with coordinating successful improvement projects
Tracking project outcomes alongside process measures
Real-time dashboards inclusive of both outcomes and process measures
Documenting PDSAs
Click here to view the Qualaris improvement projects and outcomes demo
These tools require a short setup webinar session with Qualaris
Readmission Immersion Project participants should contact supportqualariscom
Use the Qualaris virtual chat support for next steps
45
LEAN Six Sigma Green Belt Project
Project launching mdashMarch 13 2018 through November 30 2018
Hospitals committed mdash20
Topic-focused
Patient throughput
ICU harm reduction
Errors in medication reconciliation
46
Capital Region Medical Center
Carroll County Memorial Hospital
Cass Regional Medical Center
Cox Medical Center
Fitzgibbon Hospital
Golden Valley Memorial Healthcare
Hannibal Regional Hospital
Lafayette Regional Health Center
Lake Regional Health System
Liberty Hospital
North Kansas City Hospital
Ozark Medical Center
Perry County Memorial Hospital
Saint Lukes Health System
Saint Lukes Hospital Kansas City
Scotland County Hospital
Southeast Missouri Hospital
St Marys Medical Center
Ste Genevieve County Memorial Hospital
Western Missouri Medical Center
NHSN Reporting Facilities
The January 23rd release of the NHSN 881 application will introduce an updated NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled in NHSN prior to December 2 2017 Facilities that enrolled in NHSN on or after December 2 2017 have already accessed this new Consent and will not need to accept it again if they have already done so
Primary Contacts or Facility Administrators should agree to this updated Consent form for each component by April 14th 2018 or risk losing access to NHSN
An alert will appear on all NHSN component home pages and primary contacts and facility administrators will receive an email notification
Additional information including Frequently Asked Questions and the updated NHSN purposes are available on CDCs NHSN website If you have any questions please send an email to NHSNcdcgov with the subject line ldquoNHSN Reconsentrdquo
47
NHSN Reporting Facilities
The NHSN team has published informational guidance on our website to assist users with completion of the updated NHSN Agreement to Participate and Consent A 5-minute video informs users of the new Consent purposes and the simple process for accepting the Consent electronically Furthermore a step-by-step guidance document provides detailed instructions and screen shots for what Facility Administrators and Primary Contacts can expect to see when they begin the re-consent process in the NHSN application A link to the video and the guidance document can both be found in the FAQs About NHSNrsquos Agreement to Participate and Consent
48
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
Confirmed State
Decrease HF readmissions from 202 in 2016 to 153 in 2017
Decrease COPD readmissions 198 in 2016 to 144 in 2017
Decrease PN readmissions from 122 in 2016 to 114 in 2017
Maintain AMI and CABG readmissions at better than the 90th percentile in 2017
23
Questions
24
Readmissions UpdateJosh Grotzinger
25
ICD-10 Readmission Update
October 2015 HIDI developed a GEM-mapped approach to the CMSYale risk-adjusted readmission models to accommodate ICD-9 and ICD-10 codes This action was taken prior to the availability of final ICD-910 compliant models from CMSYale to ensure continuity of readmission reporting for HIDI-participating hospitals
CMSYale released new ICD-910 compliant risk-adjusted readmission models with the release of the 2017 Hospital Compare data
26
CMSYale Documentation
CMSYale have validated their ICD-910 compliant models with documentation on QualityNet
Documentation on additionsexclusions from the cohort definitions are available through CMSYale on QualityNet
HIDI observed very modest levels of variation between the readmission models (HIDI GEM-mapped and CMSYale ICD-910 compliant)
27
Whatrsquos Coming after HIINJessica Stultz
28
Missouri Harm Dashboard
29
Missouri Harm Dashboard
MHA board initiative
Three harms
CAUTI
CLABSI
CDI
Reduce state rate by 10 percent
30
Missouri Harm Dashboard
All Missouri acute care hospitals
Excludes rehab psych LTAC womenrsquos childrens specialty veteransmilitary
Distributed to CEOs quarterly
2017 Q4 dashboard was distributed at district council last week
Targeted education materials to be sent at the leadership level
31
Missouri Harm Dashboard
Includes NHSN data only
Measuring improvement of rates
Most recent SIR will be shown on dashboard
Measuring improvement over state target
Calendar year 2016 baseline
Data will be pulled quarterly
2017 Q4 distributed March 2018
2018 Q1 will be distributed June 2018
32
33
HIIN Regional Boot Camps
To Increase Workersrsquo Safety
34
What to Expect
Attendees will be taught and have the opportunity to demonstrate
De-escalation management
Crisis intervention training to supplement the de-escalation techniques with a focus on mental health populations
Components of rape aggression defense training will be taught to offer realistic self-defense tactics and techniques
35
What to Expect
A holistic approach to reducing both the risk and anxiety surrounding violence in healthcare
Excellent supplement to existing safety programs already in place at your organizations
Offered at no cost to Missouri HRET-HIIN hospitals
Audience
front line staff in all care units (ED critical care and medical-surgical units)
safety and security personnel36
Locations and Times
Workplace safety
Blue Springs
ndash April 11 2018 at the Courtyard Marriott ndash Adams Pointe Conference Center
Springfield
ndash April 25 2018 at the Oasis Hotel and Convention Center
St Charles
ndash May 2 2018 at the Embassy Suites Hotel
Cape Girardeau
ndash May 9 2018 at the Drury Plaza Hotel Conference Center
37
HIIN Project Updates
38
Data Due Dates mdash HIIN Project Year 2
39
MHA ldquoZero Heroesrdquo Club
MHA congratulates the following HIIN-participating hospitals with the most zero harm measures reported These organizations have either achieved andor sustained a zero rate of harm and are in the top 10 percent of HIIN-participating hospitals Congratulations to the ldquoZero Herosrdquo for the month of September
Carroll County Memorial Hospital
Ellett Memorial Hospital
Harrison County Community Hospital
Iron County Medical Center
Osage Beach Center for Cognitive Disorders
Pike County Memorial Hospital
Southeast Health Center of Ripley County
Sullivan County Memorial Hospital
40
AHArsquos IT department investigated the emails and discovered they were generated by groups from Germany and Switzerland AHA recommends that your IT department block emails from these two countries unless you do business with them
SPAM Email from HEN or HIIN Finance mdash PLEASE IGNORE
If you receive an email asking you to pay your invoice via a link please ignore and permanently delete Do not click on the link in the email The email may come from different email addresses but is titled as HENHIIN Finance or HRET HIIN similar to what is pictured below
41
Hospital Leadership and Quality Assessment Tool
The tool measures board members C-suite executives and managementsupervisors on how well they are implementing evidence-based practices shown to support a culture of safety and high performance in clinical quality measures
No front-line staff survey component
Survey content
FAQ
42
HLQAT Survey
MHA is providing this complimentary opportunity for all HIIN hospitals to access and utilize this survey
Two options
Phase I mdash Completed
Phase II mdash April through August 2018
ndash Available to all HIIN hospitals mdash previous participation not
required
ndash Phase I hospitals may participate in phase II if desired
ndash Intent to participate materials will be sent to HIIN contacts soon
43
Qualaris Audit Tool Projects
Hand Hygiene
Culture of Safety Rounding
Sepsis
ReadmissionsCare Transitions
44
Qualaris mdash New Tools
Qualaris has new tools to assist users with coordinating successful improvement projects
Tracking project outcomes alongside process measures
Real-time dashboards inclusive of both outcomes and process measures
Documenting PDSAs
Click here to view the Qualaris improvement projects and outcomes demo
These tools require a short setup webinar session with Qualaris
Readmission Immersion Project participants should contact supportqualariscom
Use the Qualaris virtual chat support for next steps
45
LEAN Six Sigma Green Belt Project
Project launching mdashMarch 13 2018 through November 30 2018
Hospitals committed mdash20
Topic-focused
Patient throughput
ICU harm reduction
Errors in medication reconciliation
46
Capital Region Medical Center
Carroll County Memorial Hospital
Cass Regional Medical Center
Cox Medical Center
Fitzgibbon Hospital
Golden Valley Memorial Healthcare
Hannibal Regional Hospital
Lafayette Regional Health Center
Lake Regional Health System
Liberty Hospital
North Kansas City Hospital
Ozark Medical Center
Perry County Memorial Hospital
Saint Lukes Health System
Saint Lukes Hospital Kansas City
Scotland County Hospital
Southeast Missouri Hospital
St Marys Medical Center
Ste Genevieve County Memorial Hospital
Western Missouri Medical Center
NHSN Reporting Facilities
The January 23rd release of the NHSN 881 application will introduce an updated NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled in NHSN prior to December 2 2017 Facilities that enrolled in NHSN on or after December 2 2017 have already accessed this new Consent and will not need to accept it again if they have already done so
Primary Contacts or Facility Administrators should agree to this updated Consent form for each component by April 14th 2018 or risk losing access to NHSN
An alert will appear on all NHSN component home pages and primary contacts and facility administrators will receive an email notification
Additional information including Frequently Asked Questions and the updated NHSN purposes are available on CDCs NHSN website If you have any questions please send an email to NHSNcdcgov with the subject line ldquoNHSN Reconsentrdquo
47
NHSN Reporting Facilities
The NHSN team has published informational guidance on our website to assist users with completion of the updated NHSN Agreement to Participate and Consent A 5-minute video informs users of the new Consent purposes and the simple process for accepting the Consent electronically Furthermore a step-by-step guidance document provides detailed instructions and screen shots for what Facility Administrators and Primary Contacts can expect to see when they begin the re-consent process in the NHSN application A link to the video and the guidance document can both be found in the FAQs About NHSNrsquos Agreement to Participate and Consent
48
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
Questions
24
Readmissions UpdateJosh Grotzinger
25
ICD-10 Readmission Update
October 2015 HIDI developed a GEM-mapped approach to the CMSYale risk-adjusted readmission models to accommodate ICD-9 and ICD-10 codes This action was taken prior to the availability of final ICD-910 compliant models from CMSYale to ensure continuity of readmission reporting for HIDI-participating hospitals
CMSYale released new ICD-910 compliant risk-adjusted readmission models with the release of the 2017 Hospital Compare data
26
CMSYale Documentation
CMSYale have validated their ICD-910 compliant models with documentation on QualityNet
Documentation on additionsexclusions from the cohort definitions are available through CMSYale on QualityNet
HIDI observed very modest levels of variation between the readmission models (HIDI GEM-mapped and CMSYale ICD-910 compliant)
27
Whatrsquos Coming after HIINJessica Stultz
28
Missouri Harm Dashboard
29
Missouri Harm Dashboard
MHA board initiative
Three harms
CAUTI
CLABSI
CDI
Reduce state rate by 10 percent
30
Missouri Harm Dashboard
All Missouri acute care hospitals
Excludes rehab psych LTAC womenrsquos childrens specialty veteransmilitary
Distributed to CEOs quarterly
2017 Q4 dashboard was distributed at district council last week
Targeted education materials to be sent at the leadership level
31
Missouri Harm Dashboard
Includes NHSN data only
Measuring improvement of rates
Most recent SIR will be shown on dashboard
Measuring improvement over state target
Calendar year 2016 baseline
Data will be pulled quarterly
2017 Q4 distributed March 2018
2018 Q1 will be distributed June 2018
32
33
HIIN Regional Boot Camps
To Increase Workersrsquo Safety
34
What to Expect
Attendees will be taught and have the opportunity to demonstrate
De-escalation management
Crisis intervention training to supplement the de-escalation techniques with a focus on mental health populations
Components of rape aggression defense training will be taught to offer realistic self-defense tactics and techniques
35
What to Expect
A holistic approach to reducing both the risk and anxiety surrounding violence in healthcare
Excellent supplement to existing safety programs already in place at your organizations
Offered at no cost to Missouri HRET-HIIN hospitals
Audience
front line staff in all care units (ED critical care and medical-surgical units)
safety and security personnel36
Locations and Times
Workplace safety
Blue Springs
ndash April 11 2018 at the Courtyard Marriott ndash Adams Pointe Conference Center
Springfield
ndash April 25 2018 at the Oasis Hotel and Convention Center
St Charles
ndash May 2 2018 at the Embassy Suites Hotel
Cape Girardeau
ndash May 9 2018 at the Drury Plaza Hotel Conference Center
37
HIIN Project Updates
38
Data Due Dates mdash HIIN Project Year 2
39
MHA ldquoZero Heroesrdquo Club
MHA congratulates the following HIIN-participating hospitals with the most zero harm measures reported These organizations have either achieved andor sustained a zero rate of harm and are in the top 10 percent of HIIN-participating hospitals Congratulations to the ldquoZero Herosrdquo for the month of September
Carroll County Memorial Hospital
Ellett Memorial Hospital
Harrison County Community Hospital
Iron County Medical Center
Osage Beach Center for Cognitive Disorders
Pike County Memorial Hospital
Southeast Health Center of Ripley County
Sullivan County Memorial Hospital
40
AHArsquos IT department investigated the emails and discovered they were generated by groups from Germany and Switzerland AHA recommends that your IT department block emails from these two countries unless you do business with them
SPAM Email from HEN or HIIN Finance mdash PLEASE IGNORE
If you receive an email asking you to pay your invoice via a link please ignore and permanently delete Do not click on the link in the email The email may come from different email addresses but is titled as HENHIIN Finance or HRET HIIN similar to what is pictured below
41
Hospital Leadership and Quality Assessment Tool
The tool measures board members C-suite executives and managementsupervisors on how well they are implementing evidence-based practices shown to support a culture of safety and high performance in clinical quality measures
No front-line staff survey component
Survey content
FAQ
42
HLQAT Survey
MHA is providing this complimentary opportunity for all HIIN hospitals to access and utilize this survey
Two options
Phase I mdash Completed
Phase II mdash April through August 2018
ndash Available to all HIIN hospitals mdash previous participation not
required
ndash Phase I hospitals may participate in phase II if desired
ndash Intent to participate materials will be sent to HIIN contacts soon
43
Qualaris Audit Tool Projects
Hand Hygiene
Culture of Safety Rounding
Sepsis
ReadmissionsCare Transitions
44
Qualaris mdash New Tools
Qualaris has new tools to assist users with coordinating successful improvement projects
Tracking project outcomes alongside process measures
Real-time dashboards inclusive of both outcomes and process measures
Documenting PDSAs
Click here to view the Qualaris improvement projects and outcomes demo
These tools require a short setup webinar session with Qualaris
Readmission Immersion Project participants should contact supportqualariscom
Use the Qualaris virtual chat support for next steps
45
LEAN Six Sigma Green Belt Project
Project launching mdashMarch 13 2018 through November 30 2018
Hospitals committed mdash20
Topic-focused
Patient throughput
ICU harm reduction
Errors in medication reconciliation
46
Capital Region Medical Center
Carroll County Memorial Hospital
Cass Regional Medical Center
Cox Medical Center
Fitzgibbon Hospital
Golden Valley Memorial Healthcare
Hannibal Regional Hospital
Lafayette Regional Health Center
Lake Regional Health System
Liberty Hospital
North Kansas City Hospital
Ozark Medical Center
Perry County Memorial Hospital
Saint Lukes Health System
Saint Lukes Hospital Kansas City
Scotland County Hospital
Southeast Missouri Hospital
St Marys Medical Center
Ste Genevieve County Memorial Hospital
Western Missouri Medical Center
NHSN Reporting Facilities
The January 23rd release of the NHSN 881 application will introduce an updated NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled in NHSN prior to December 2 2017 Facilities that enrolled in NHSN on or after December 2 2017 have already accessed this new Consent and will not need to accept it again if they have already done so
Primary Contacts or Facility Administrators should agree to this updated Consent form for each component by April 14th 2018 or risk losing access to NHSN
An alert will appear on all NHSN component home pages and primary contacts and facility administrators will receive an email notification
Additional information including Frequently Asked Questions and the updated NHSN purposes are available on CDCs NHSN website If you have any questions please send an email to NHSNcdcgov with the subject line ldquoNHSN Reconsentrdquo
47
NHSN Reporting Facilities
The NHSN team has published informational guidance on our website to assist users with completion of the updated NHSN Agreement to Participate and Consent A 5-minute video informs users of the new Consent purposes and the simple process for accepting the Consent electronically Furthermore a step-by-step guidance document provides detailed instructions and screen shots for what Facility Administrators and Primary Contacts can expect to see when they begin the re-consent process in the NHSN application A link to the video and the guidance document can both be found in the FAQs About NHSNrsquos Agreement to Participate and Consent
48
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
Readmissions UpdateJosh Grotzinger
25
ICD-10 Readmission Update
October 2015 HIDI developed a GEM-mapped approach to the CMSYale risk-adjusted readmission models to accommodate ICD-9 and ICD-10 codes This action was taken prior to the availability of final ICD-910 compliant models from CMSYale to ensure continuity of readmission reporting for HIDI-participating hospitals
CMSYale released new ICD-910 compliant risk-adjusted readmission models with the release of the 2017 Hospital Compare data
26
CMSYale Documentation
CMSYale have validated their ICD-910 compliant models with documentation on QualityNet
Documentation on additionsexclusions from the cohort definitions are available through CMSYale on QualityNet
HIDI observed very modest levels of variation between the readmission models (HIDI GEM-mapped and CMSYale ICD-910 compliant)
27
Whatrsquos Coming after HIINJessica Stultz
28
Missouri Harm Dashboard
29
Missouri Harm Dashboard
MHA board initiative
Three harms
CAUTI
CLABSI
CDI
Reduce state rate by 10 percent
30
Missouri Harm Dashboard
All Missouri acute care hospitals
Excludes rehab psych LTAC womenrsquos childrens specialty veteransmilitary
Distributed to CEOs quarterly
2017 Q4 dashboard was distributed at district council last week
Targeted education materials to be sent at the leadership level
31
Missouri Harm Dashboard
Includes NHSN data only
Measuring improvement of rates
Most recent SIR will be shown on dashboard
Measuring improvement over state target
Calendar year 2016 baseline
Data will be pulled quarterly
2017 Q4 distributed March 2018
2018 Q1 will be distributed June 2018
32
33
HIIN Regional Boot Camps
To Increase Workersrsquo Safety
34
What to Expect
Attendees will be taught and have the opportunity to demonstrate
De-escalation management
Crisis intervention training to supplement the de-escalation techniques with a focus on mental health populations
Components of rape aggression defense training will be taught to offer realistic self-defense tactics and techniques
35
What to Expect
A holistic approach to reducing both the risk and anxiety surrounding violence in healthcare
Excellent supplement to existing safety programs already in place at your organizations
Offered at no cost to Missouri HRET-HIIN hospitals
Audience
front line staff in all care units (ED critical care and medical-surgical units)
safety and security personnel36
Locations and Times
Workplace safety
Blue Springs
ndash April 11 2018 at the Courtyard Marriott ndash Adams Pointe Conference Center
Springfield
ndash April 25 2018 at the Oasis Hotel and Convention Center
St Charles
ndash May 2 2018 at the Embassy Suites Hotel
Cape Girardeau
ndash May 9 2018 at the Drury Plaza Hotel Conference Center
37
HIIN Project Updates
38
Data Due Dates mdash HIIN Project Year 2
39
MHA ldquoZero Heroesrdquo Club
MHA congratulates the following HIIN-participating hospitals with the most zero harm measures reported These organizations have either achieved andor sustained a zero rate of harm and are in the top 10 percent of HIIN-participating hospitals Congratulations to the ldquoZero Herosrdquo for the month of September
Carroll County Memorial Hospital
Ellett Memorial Hospital
Harrison County Community Hospital
Iron County Medical Center
Osage Beach Center for Cognitive Disorders
Pike County Memorial Hospital
Southeast Health Center of Ripley County
Sullivan County Memorial Hospital
40
AHArsquos IT department investigated the emails and discovered they were generated by groups from Germany and Switzerland AHA recommends that your IT department block emails from these two countries unless you do business with them
SPAM Email from HEN or HIIN Finance mdash PLEASE IGNORE
If you receive an email asking you to pay your invoice via a link please ignore and permanently delete Do not click on the link in the email The email may come from different email addresses but is titled as HENHIIN Finance or HRET HIIN similar to what is pictured below
41
Hospital Leadership and Quality Assessment Tool
The tool measures board members C-suite executives and managementsupervisors on how well they are implementing evidence-based practices shown to support a culture of safety and high performance in clinical quality measures
No front-line staff survey component
Survey content
FAQ
42
HLQAT Survey
MHA is providing this complimentary opportunity for all HIIN hospitals to access and utilize this survey
Two options
Phase I mdash Completed
Phase II mdash April through August 2018
ndash Available to all HIIN hospitals mdash previous participation not
required
ndash Phase I hospitals may participate in phase II if desired
ndash Intent to participate materials will be sent to HIIN contacts soon
43
Qualaris Audit Tool Projects
Hand Hygiene
Culture of Safety Rounding
Sepsis
ReadmissionsCare Transitions
44
Qualaris mdash New Tools
Qualaris has new tools to assist users with coordinating successful improvement projects
Tracking project outcomes alongside process measures
Real-time dashboards inclusive of both outcomes and process measures
Documenting PDSAs
Click here to view the Qualaris improvement projects and outcomes demo
These tools require a short setup webinar session with Qualaris
Readmission Immersion Project participants should contact supportqualariscom
Use the Qualaris virtual chat support for next steps
45
LEAN Six Sigma Green Belt Project
Project launching mdashMarch 13 2018 through November 30 2018
Hospitals committed mdash20
Topic-focused
Patient throughput
ICU harm reduction
Errors in medication reconciliation
46
Capital Region Medical Center
Carroll County Memorial Hospital
Cass Regional Medical Center
Cox Medical Center
Fitzgibbon Hospital
Golden Valley Memorial Healthcare
Hannibal Regional Hospital
Lafayette Regional Health Center
Lake Regional Health System
Liberty Hospital
North Kansas City Hospital
Ozark Medical Center
Perry County Memorial Hospital
Saint Lukes Health System
Saint Lukes Hospital Kansas City
Scotland County Hospital
Southeast Missouri Hospital
St Marys Medical Center
Ste Genevieve County Memorial Hospital
Western Missouri Medical Center
NHSN Reporting Facilities
The January 23rd release of the NHSN 881 application will introduce an updated NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled in NHSN prior to December 2 2017 Facilities that enrolled in NHSN on or after December 2 2017 have already accessed this new Consent and will not need to accept it again if they have already done so
Primary Contacts or Facility Administrators should agree to this updated Consent form for each component by April 14th 2018 or risk losing access to NHSN
An alert will appear on all NHSN component home pages and primary contacts and facility administrators will receive an email notification
Additional information including Frequently Asked Questions and the updated NHSN purposes are available on CDCs NHSN website If you have any questions please send an email to NHSNcdcgov with the subject line ldquoNHSN Reconsentrdquo
47
NHSN Reporting Facilities
The NHSN team has published informational guidance on our website to assist users with completion of the updated NHSN Agreement to Participate and Consent A 5-minute video informs users of the new Consent purposes and the simple process for accepting the Consent electronically Furthermore a step-by-step guidance document provides detailed instructions and screen shots for what Facility Administrators and Primary Contacts can expect to see when they begin the re-consent process in the NHSN application A link to the video and the guidance document can both be found in the FAQs About NHSNrsquos Agreement to Participate and Consent
48
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
ICD-10 Readmission Update
October 2015 HIDI developed a GEM-mapped approach to the CMSYale risk-adjusted readmission models to accommodate ICD-9 and ICD-10 codes This action was taken prior to the availability of final ICD-910 compliant models from CMSYale to ensure continuity of readmission reporting for HIDI-participating hospitals
CMSYale released new ICD-910 compliant risk-adjusted readmission models with the release of the 2017 Hospital Compare data
26
CMSYale Documentation
CMSYale have validated their ICD-910 compliant models with documentation on QualityNet
Documentation on additionsexclusions from the cohort definitions are available through CMSYale on QualityNet
HIDI observed very modest levels of variation between the readmission models (HIDI GEM-mapped and CMSYale ICD-910 compliant)
27
Whatrsquos Coming after HIINJessica Stultz
28
Missouri Harm Dashboard
29
Missouri Harm Dashboard
MHA board initiative
Three harms
CAUTI
CLABSI
CDI
Reduce state rate by 10 percent
30
Missouri Harm Dashboard
All Missouri acute care hospitals
Excludes rehab psych LTAC womenrsquos childrens specialty veteransmilitary
Distributed to CEOs quarterly
2017 Q4 dashboard was distributed at district council last week
Targeted education materials to be sent at the leadership level
31
Missouri Harm Dashboard
Includes NHSN data only
Measuring improvement of rates
Most recent SIR will be shown on dashboard
Measuring improvement over state target
Calendar year 2016 baseline
Data will be pulled quarterly
2017 Q4 distributed March 2018
2018 Q1 will be distributed June 2018
32
33
HIIN Regional Boot Camps
To Increase Workersrsquo Safety
34
What to Expect
Attendees will be taught and have the opportunity to demonstrate
De-escalation management
Crisis intervention training to supplement the de-escalation techniques with a focus on mental health populations
Components of rape aggression defense training will be taught to offer realistic self-defense tactics and techniques
35
What to Expect
A holistic approach to reducing both the risk and anxiety surrounding violence in healthcare
Excellent supplement to existing safety programs already in place at your organizations
Offered at no cost to Missouri HRET-HIIN hospitals
Audience
front line staff in all care units (ED critical care and medical-surgical units)
safety and security personnel36
Locations and Times
Workplace safety
Blue Springs
ndash April 11 2018 at the Courtyard Marriott ndash Adams Pointe Conference Center
Springfield
ndash April 25 2018 at the Oasis Hotel and Convention Center
St Charles
ndash May 2 2018 at the Embassy Suites Hotel
Cape Girardeau
ndash May 9 2018 at the Drury Plaza Hotel Conference Center
37
HIIN Project Updates
38
Data Due Dates mdash HIIN Project Year 2
39
MHA ldquoZero Heroesrdquo Club
MHA congratulates the following HIIN-participating hospitals with the most zero harm measures reported These organizations have either achieved andor sustained a zero rate of harm and are in the top 10 percent of HIIN-participating hospitals Congratulations to the ldquoZero Herosrdquo for the month of September
Carroll County Memorial Hospital
Ellett Memorial Hospital
Harrison County Community Hospital
Iron County Medical Center
Osage Beach Center for Cognitive Disorders
Pike County Memorial Hospital
Southeast Health Center of Ripley County
Sullivan County Memorial Hospital
40
AHArsquos IT department investigated the emails and discovered they were generated by groups from Germany and Switzerland AHA recommends that your IT department block emails from these two countries unless you do business with them
SPAM Email from HEN or HIIN Finance mdash PLEASE IGNORE
If you receive an email asking you to pay your invoice via a link please ignore and permanently delete Do not click on the link in the email The email may come from different email addresses but is titled as HENHIIN Finance or HRET HIIN similar to what is pictured below
41
Hospital Leadership and Quality Assessment Tool
The tool measures board members C-suite executives and managementsupervisors on how well they are implementing evidence-based practices shown to support a culture of safety and high performance in clinical quality measures
No front-line staff survey component
Survey content
FAQ
42
HLQAT Survey
MHA is providing this complimentary opportunity for all HIIN hospitals to access and utilize this survey
Two options
Phase I mdash Completed
Phase II mdash April through August 2018
ndash Available to all HIIN hospitals mdash previous participation not
required
ndash Phase I hospitals may participate in phase II if desired
ndash Intent to participate materials will be sent to HIIN contacts soon
43
Qualaris Audit Tool Projects
Hand Hygiene
Culture of Safety Rounding
Sepsis
ReadmissionsCare Transitions
44
Qualaris mdash New Tools
Qualaris has new tools to assist users with coordinating successful improvement projects
Tracking project outcomes alongside process measures
Real-time dashboards inclusive of both outcomes and process measures
Documenting PDSAs
Click here to view the Qualaris improvement projects and outcomes demo
These tools require a short setup webinar session with Qualaris
Readmission Immersion Project participants should contact supportqualariscom
Use the Qualaris virtual chat support for next steps
45
LEAN Six Sigma Green Belt Project
Project launching mdashMarch 13 2018 through November 30 2018
Hospitals committed mdash20
Topic-focused
Patient throughput
ICU harm reduction
Errors in medication reconciliation
46
Capital Region Medical Center
Carroll County Memorial Hospital
Cass Regional Medical Center
Cox Medical Center
Fitzgibbon Hospital
Golden Valley Memorial Healthcare
Hannibal Regional Hospital
Lafayette Regional Health Center
Lake Regional Health System
Liberty Hospital
North Kansas City Hospital
Ozark Medical Center
Perry County Memorial Hospital
Saint Lukes Health System
Saint Lukes Hospital Kansas City
Scotland County Hospital
Southeast Missouri Hospital
St Marys Medical Center
Ste Genevieve County Memorial Hospital
Western Missouri Medical Center
NHSN Reporting Facilities
The January 23rd release of the NHSN 881 application will introduce an updated NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled in NHSN prior to December 2 2017 Facilities that enrolled in NHSN on or after December 2 2017 have already accessed this new Consent and will not need to accept it again if they have already done so
Primary Contacts or Facility Administrators should agree to this updated Consent form for each component by April 14th 2018 or risk losing access to NHSN
An alert will appear on all NHSN component home pages and primary contacts and facility administrators will receive an email notification
Additional information including Frequently Asked Questions and the updated NHSN purposes are available on CDCs NHSN website If you have any questions please send an email to NHSNcdcgov with the subject line ldquoNHSN Reconsentrdquo
47
NHSN Reporting Facilities
The NHSN team has published informational guidance on our website to assist users with completion of the updated NHSN Agreement to Participate and Consent A 5-minute video informs users of the new Consent purposes and the simple process for accepting the Consent electronically Furthermore a step-by-step guidance document provides detailed instructions and screen shots for what Facility Administrators and Primary Contacts can expect to see when they begin the re-consent process in the NHSN application A link to the video and the guidance document can both be found in the FAQs About NHSNrsquos Agreement to Participate and Consent
48
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
CMSYale Documentation
CMSYale have validated their ICD-910 compliant models with documentation on QualityNet
Documentation on additionsexclusions from the cohort definitions are available through CMSYale on QualityNet
HIDI observed very modest levels of variation between the readmission models (HIDI GEM-mapped and CMSYale ICD-910 compliant)
27
Whatrsquos Coming after HIINJessica Stultz
28
Missouri Harm Dashboard
29
Missouri Harm Dashboard
MHA board initiative
Three harms
CAUTI
CLABSI
CDI
Reduce state rate by 10 percent
30
Missouri Harm Dashboard
All Missouri acute care hospitals
Excludes rehab psych LTAC womenrsquos childrens specialty veteransmilitary
Distributed to CEOs quarterly
2017 Q4 dashboard was distributed at district council last week
Targeted education materials to be sent at the leadership level
31
Missouri Harm Dashboard
Includes NHSN data only
Measuring improvement of rates
Most recent SIR will be shown on dashboard
Measuring improvement over state target
Calendar year 2016 baseline
Data will be pulled quarterly
2017 Q4 distributed March 2018
2018 Q1 will be distributed June 2018
32
33
HIIN Regional Boot Camps
To Increase Workersrsquo Safety
34
What to Expect
Attendees will be taught and have the opportunity to demonstrate
De-escalation management
Crisis intervention training to supplement the de-escalation techniques with a focus on mental health populations
Components of rape aggression defense training will be taught to offer realistic self-defense tactics and techniques
35
What to Expect
A holistic approach to reducing both the risk and anxiety surrounding violence in healthcare
Excellent supplement to existing safety programs already in place at your organizations
Offered at no cost to Missouri HRET-HIIN hospitals
Audience
front line staff in all care units (ED critical care and medical-surgical units)
safety and security personnel36
Locations and Times
Workplace safety
Blue Springs
ndash April 11 2018 at the Courtyard Marriott ndash Adams Pointe Conference Center
Springfield
ndash April 25 2018 at the Oasis Hotel and Convention Center
St Charles
ndash May 2 2018 at the Embassy Suites Hotel
Cape Girardeau
ndash May 9 2018 at the Drury Plaza Hotel Conference Center
37
HIIN Project Updates
38
Data Due Dates mdash HIIN Project Year 2
39
MHA ldquoZero Heroesrdquo Club
MHA congratulates the following HIIN-participating hospitals with the most zero harm measures reported These organizations have either achieved andor sustained a zero rate of harm and are in the top 10 percent of HIIN-participating hospitals Congratulations to the ldquoZero Herosrdquo for the month of September
Carroll County Memorial Hospital
Ellett Memorial Hospital
Harrison County Community Hospital
Iron County Medical Center
Osage Beach Center for Cognitive Disorders
Pike County Memorial Hospital
Southeast Health Center of Ripley County
Sullivan County Memorial Hospital
40
AHArsquos IT department investigated the emails and discovered they were generated by groups from Germany and Switzerland AHA recommends that your IT department block emails from these two countries unless you do business with them
SPAM Email from HEN or HIIN Finance mdash PLEASE IGNORE
If you receive an email asking you to pay your invoice via a link please ignore and permanently delete Do not click on the link in the email The email may come from different email addresses but is titled as HENHIIN Finance or HRET HIIN similar to what is pictured below
41
Hospital Leadership and Quality Assessment Tool
The tool measures board members C-suite executives and managementsupervisors on how well they are implementing evidence-based practices shown to support a culture of safety and high performance in clinical quality measures
No front-line staff survey component
Survey content
FAQ
42
HLQAT Survey
MHA is providing this complimentary opportunity for all HIIN hospitals to access and utilize this survey
Two options
Phase I mdash Completed
Phase II mdash April through August 2018
ndash Available to all HIIN hospitals mdash previous participation not
required
ndash Phase I hospitals may participate in phase II if desired
ndash Intent to participate materials will be sent to HIIN contacts soon
43
Qualaris Audit Tool Projects
Hand Hygiene
Culture of Safety Rounding
Sepsis
ReadmissionsCare Transitions
44
Qualaris mdash New Tools
Qualaris has new tools to assist users with coordinating successful improvement projects
Tracking project outcomes alongside process measures
Real-time dashboards inclusive of both outcomes and process measures
Documenting PDSAs
Click here to view the Qualaris improvement projects and outcomes demo
These tools require a short setup webinar session with Qualaris
Readmission Immersion Project participants should contact supportqualariscom
Use the Qualaris virtual chat support for next steps
45
LEAN Six Sigma Green Belt Project
Project launching mdashMarch 13 2018 through November 30 2018
Hospitals committed mdash20
Topic-focused
Patient throughput
ICU harm reduction
Errors in medication reconciliation
46
Capital Region Medical Center
Carroll County Memorial Hospital
Cass Regional Medical Center
Cox Medical Center
Fitzgibbon Hospital
Golden Valley Memorial Healthcare
Hannibal Regional Hospital
Lafayette Regional Health Center
Lake Regional Health System
Liberty Hospital
North Kansas City Hospital
Ozark Medical Center
Perry County Memorial Hospital
Saint Lukes Health System
Saint Lukes Hospital Kansas City
Scotland County Hospital
Southeast Missouri Hospital
St Marys Medical Center
Ste Genevieve County Memorial Hospital
Western Missouri Medical Center
NHSN Reporting Facilities
The January 23rd release of the NHSN 881 application will introduce an updated NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled in NHSN prior to December 2 2017 Facilities that enrolled in NHSN on or after December 2 2017 have already accessed this new Consent and will not need to accept it again if they have already done so
Primary Contacts or Facility Administrators should agree to this updated Consent form for each component by April 14th 2018 or risk losing access to NHSN
An alert will appear on all NHSN component home pages and primary contacts and facility administrators will receive an email notification
Additional information including Frequently Asked Questions and the updated NHSN purposes are available on CDCs NHSN website If you have any questions please send an email to NHSNcdcgov with the subject line ldquoNHSN Reconsentrdquo
47
NHSN Reporting Facilities
The NHSN team has published informational guidance on our website to assist users with completion of the updated NHSN Agreement to Participate and Consent A 5-minute video informs users of the new Consent purposes and the simple process for accepting the Consent electronically Furthermore a step-by-step guidance document provides detailed instructions and screen shots for what Facility Administrators and Primary Contacts can expect to see when they begin the re-consent process in the NHSN application A link to the video and the guidance document can both be found in the FAQs About NHSNrsquos Agreement to Participate and Consent
48
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
Whatrsquos Coming after HIINJessica Stultz
28
Missouri Harm Dashboard
29
Missouri Harm Dashboard
MHA board initiative
Three harms
CAUTI
CLABSI
CDI
Reduce state rate by 10 percent
30
Missouri Harm Dashboard
All Missouri acute care hospitals
Excludes rehab psych LTAC womenrsquos childrens specialty veteransmilitary
Distributed to CEOs quarterly
2017 Q4 dashboard was distributed at district council last week
Targeted education materials to be sent at the leadership level
31
Missouri Harm Dashboard
Includes NHSN data only
Measuring improvement of rates
Most recent SIR will be shown on dashboard
Measuring improvement over state target
Calendar year 2016 baseline
Data will be pulled quarterly
2017 Q4 distributed March 2018
2018 Q1 will be distributed June 2018
32
33
HIIN Regional Boot Camps
To Increase Workersrsquo Safety
34
What to Expect
Attendees will be taught and have the opportunity to demonstrate
De-escalation management
Crisis intervention training to supplement the de-escalation techniques with a focus on mental health populations
Components of rape aggression defense training will be taught to offer realistic self-defense tactics and techniques
35
What to Expect
A holistic approach to reducing both the risk and anxiety surrounding violence in healthcare
Excellent supplement to existing safety programs already in place at your organizations
Offered at no cost to Missouri HRET-HIIN hospitals
Audience
front line staff in all care units (ED critical care and medical-surgical units)
safety and security personnel36
Locations and Times
Workplace safety
Blue Springs
ndash April 11 2018 at the Courtyard Marriott ndash Adams Pointe Conference Center
Springfield
ndash April 25 2018 at the Oasis Hotel and Convention Center
St Charles
ndash May 2 2018 at the Embassy Suites Hotel
Cape Girardeau
ndash May 9 2018 at the Drury Plaza Hotel Conference Center
37
HIIN Project Updates
38
Data Due Dates mdash HIIN Project Year 2
39
MHA ldquoZero Heroesrdquo Club
MHA congratulates the following HIIN-participating hospitals with the most zero harm measures reported These organizations have either achieved andor sustained a zero rate of harm and are in the top 10 percent of HIIN-participating hospitals Congratulations to the ldquoZero Herosrdquo for the month of September
Carroll County Memorial Hospital
Ellett Memorial Hospital
Harrison County Community Hospital
Iron County Medical Center
Osage Beach Center for Cognitive Disorders
Pike County Memorial Hospital
Southeast Health Center of Ripley County
Sullivan County Memorial Hospital
40
AHArsquos IT department investigated the emails and discovered they were generated by groups from Germany and Switzerland AHA recommends that your IT department block emails from these two countries unless you do business with them
SPAM Email from HEN or HIIN Finance mdash PLEASE IGNORE
If you receive an email asking you to pay your invoice via a link please ignore and permanently delete Do not click on the link in the email The email may come from different email addresses but is titled as HENHIIN Finance or HRET HIIN similar to what is pictured below
41
Hospital Leadership and Quality Assessment Tool
The tool measures board members C-suite executives and managementsupervisors on how well they are implementing evidence-based practices shown to support a culture of safety and high performance in clinical quality measures
No front-line staff survey component
Survey content
FAQ
42
HLQAT Survey
MHA is providing this complimentary opportunity for all HIIN hospitals to access and utilize this survey
Two options
Phase I mdash Completed
Phase II mdash April through August 2018
ndash Available to all HIIN hospitals mdash previous participation not
required
ndash Phase I hospitals may participate in phase II if desired
ndash Intent to participate materials will be sent to HIIN contacts soon
43
Qualaris Audit Tool Projects
Hand Hygiene
Culture of Safety Rounding
Sepsis
ReadmissionsCare Transitions
44
Qualaris mdash New Tools
Qualaris has new tools to assist users with coordinating successful improvement projects
Tracking project outcomes alongside process measures
Real-time dashboards inclusive of both outcomes and process measures
Documenting PDSAs
Click here to view the Qualaris improvement projects and outcomes demo
These tools require a short setup webinar session with Qualaris
Readmission Immersion Project participants should contact supportqualariscom
Use the Qualaris virtual chat support for next steps
45
LEAN Six Sigma Green Belt Project
Project launching mdashMarch 13 2018 through November 30 2018
Hospitals committed mdash20
Topic-focused
Patient throughput
ICU harm reduction
Errors in medication reconciliation
46
Capital Region Medical Center
Carroll County Memorial Hospital
Cass Regional Medical Center
Cox Medical Center
Fitzgibbon Hospital
Golden Valley Memorial Healthcare
Hannibal Regional Hospital
Lafayette Regional Health Center
Lake Regional Health System
Liberty Hospital
North Kansas City Hospital
Ozark Medical Center
Perry County Memorial Hospital
Saint Lukes Health System
Saint Lukes Hospital Kansas City
Scotland County Hospital
Southeast Missouri Hospital
St Marys Medical Center
Ste Genevieve County Memorial Hospital
Western Missouri Medical Center
NHSN Reporting Facilities
The January 23rd release of the NHSN 881 application will introduce an updated NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled in NHSN prior to December 2 2017 Facilities that enrolled in NHSN on or after December 2 2017 have already accessed this new Consent and will not need to accept it again if they have already done so
Primary Contacts or Facility Administrators should agree to this updated Consent form for each component by April 14th 2018 or risk losing access to NHSN
An alert will appear on all NHSN component home pages and primary contacts and facility administrators will receive an email notification
Additional information including Frequently Asked Questions and the updated NHSN purposes are available on CDCs NHSN website If you have any questions please send an email to NHSNcdcgov with the subject line ldquoNHSN Reconsentrdquo
47
NHSN Reporting Facilities
The NHSN team has published informational guidance on our website to assist users with completion of the updated NHSN Agreement to Participate and Consent A 5-minute video informs users of the new Consent purposes and the simple process for accepting the Consent electronically Furthermore a step-by-step guidance document provides detailed instructions and screen shots for what Facility Administrators and Primary Contacts can expect to see when they begin the re-consent process in the NHSN application A link to the video and the guidance document can both be found in the FAQs About NHSNrsquos Agreement to Participate and Consent
48
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
Missouri Harm Dashboard
29
Missouri Harm Dashboard
MHA board initiative
Three harms
CAUTI
CLABSI
CDI
Reduce state rate by 10 percent
30
Missouri Harm Dashboard
All Missouri acute care hospitals
Excludes rehab psych LTAC womenrsquos childrens specialty veteransmilitary
Distributed to CEOs quarterly
2017 Q4 dashboard was distributed at district council last week
Targeted education materials to be sent at the leadership level
31
Missouri Harm Dashboard
Includes NHSN data only
Measuring improvement of rates
Most recent SIR will be shown on dashboard
Measuring improvement over state target
Calendar year 2016 baseline
Data will be pulled quarterly
2017 Q4 distributed March 2018
2018 Q1 will be distributed June 2018
32
33
HIIN Regional Boot Camps
To Increase Workersrsquo Safety
34
What to Expect
Attendees will be taught and have the opportunity to demonstrate
De-escalation management
Crisis intervention training to supplement the de-escalation techniques with a focus on mental health populations
Components of rape aggression defense training will be taught to offer realistic self-defense tactics and techniques
35
What to Expect
A holistic approach to reducing both the risk and anxiety surrounding violence in healthcare
Excellent supplement to existing safety programs already in place at your organizations
Offered at no cost to Missouri HRET-HIIN hospitals
Audience
front line staff in all care units (ED critical care and medical-surgical units)
safety and security personnel36
Locations and Times
Workplace safety
Blue Springs
ndash April 11 2018 at the Courtyard Marriott ndash Adams Pointe Conference Center
Springfield
ndash April 25 2018 at the Oasis Hotel and Convention Center
St Charles
ndash May 2 2018 at the Embassy Suites Hotel
Cape Girardeau
ndash May 9 2018 at the Drury Plaza Hotel Conference Center
37
HIIN Project Updates
38
Data Due Dates mdash HIIN Project Year 2
39
MHA ldquoZero Heroesrdquo Club
MHA congratulates the following HIIN-participating hospitals with the most zero harm measures reported These organizations have either achieved andor sustained a zero rate of harm and are in the top 10 percent of HIIN-participating hospitals Congratulations to the ldquoZero Herosrdquo for the month of September
Carroll County Memorial Hospital
Ellett Memorial Hospital
Harrison County Community Hospital
Iron County Medical Center
Osage Beach Center for Cognitive Disorders
Pike County Memorial Hospital
Southeast Health Center of Ripley County
Sullivan County Memorial Hospital
40
AHArsquos IT department investigated the emails and discovered they were generated by groups from Germany and Switzerland AHA recommends that your IT department block emails from these two countries unless you do business with them
SPAM Email from HEN or HIIN Finance mdash PLEASE IGNORE
If you receive an email asking you to pay your invoice via a link please ignore and permanently delete Do not click on the link in the email The email may come from different email addresses but is titled as HENHIIN Finance or HRET HIIN similar to what is pictured below
41
Hospital Leadership and Quality Assessment Tool
The tool measures board members C-suite executives and managementsupervisors on how well they are implementing evidence-based practices shown to support a culture of safety and high performance in clinical quality measures
No front-line staff survey component
Survey content
FAQ
42
HLQAT Survey
MHA is providing this complimentary opportunity for all HIIN hospitals to access and utilize this survey
Two options
Phase I mdash Completed
Phase II mdash April through August 2018
ndash Available to all HIIN hospitals mdash previous participation not
required
ndash Phase I hospitals may participate in phase II if desired
ndash Intent to participate materials will be sent to HIIN contacts soon
43
Qualaris Audit Tool Projects
Hand Hygiene
Culture of Safety Rounding
Sepsis
ReadmissionsCare Transitions
44
Qualaris mdash New Tools
Qualaris has new tools to assist users with coordinating successful improvement projects
Tracking project outcomes alongside process measures
Real-time dashboards inclusive of both outcomes and process measures
Documenting PDSAs
Click here to view the Qualaris improvement projects and outcomes demo
These tools require a short setup webinar session with Qualaris
Readmission Immersion Project participants should contact supportqualariscom
Use the Qualaris virtual chat support for next steps
45
LEAN Six Sigma Green Belt Project
Project launching mdashMarch 13 2018 through November 30 2018
Hospitals committed mdash20
Topic-focused
Patient throughput
ICU harm reduction
Errors in medication reconciliation
46
Capital Region Medical Center
Carroll County Memorial Hospital
Cass Regional Medical Center
Cox Medical Center
Fitzgibbon Hospital
Golden Valley Memorial Healthcare
Hannibal Regional Hospital
Lafayette Regional Health Center
Lake Regional Health System
Liberty Hospital
North Kansas City Hospital
Ozark Medical Center
Perry County Memorial Hospital
Saint Lukes Health System
Saint Lukes Hospital Kansas City
Scotland County Hospital
Southeast Missouri Hospital
St Marys Medical Center
Ste Genevieve County Memorial Hospital
Western Missouri Medical Center
NHSN Reporting Facilities
The January 23rd release of the NHSN 881 application will introduce an updated NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled in NHSN prior to December 2 2017 Facilities that enrolled in NHSN on or after December 2 2017 have already accessed this new Consent and will not need to accept it again if they have already done so
Primary Contacts or Facility Administrators should agree to this updated Consent form for each component by April 14th 2018 or risk losing access to NHSN
An alert will appear on all NHSN component home pages and primary contacts and facility administrators will receive an email notification
Additional information including Frequently Asked Questions and the updated NHSN purposes are available on CDCs NHSN website If you have any questions please send an email to NHSNcdcgov with the subject line ldquoNHSN Reconsentrdquo
47
NHSN Reporting Facilities
The NHSN team has published informational guidance on our website to assist users with completion of the updated NHSN Agreement to Participate and Consent A 5-minute video informs users of the new Consent purposes and the simple process for accepting the Consent electronically Furthermore a step-by-step guidance document provides detailed instructions and screen shots for what Facility Administrators and Primary Contacts can expect to see when they begin the re-consent process in the NHSN application A link to the video and the guidance document can both be found in the FAQs About NHSNrsquos Agreement to Participate and Consent
48
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
Missouri Harm Dashboard
MHA board initiative
Three harms
CAUTI
CLABSI
CDI
Reduce state rate by 10 percent
30
Missouri Harm Dashboard
All Missouri acute care hospitals
Excludes rehab psych LTAC womenrsquos childrens specialty veteransmilitary
Distributed to CEOs quarterly
2017 Q4 dashboard was distributed at district council last week
Targeted education materials to be sent at the leadership level
31
Missouri Harm Dashboard
Includes NHSN data only
Measuring improvement of rates
Most recent SIR will be shown on dashboard
Measuring improvement over state target
Calendar year 2016 baseline
Data will be pulled quarterly
2017 Q4 distributed March 2018
2018 Q1 will be distributed June 2018
32
33
HIIN Regional Boot Camps
To Increase Workersrsquo Safety
34
What to Expect
Attendees will be taught and have the opportunity to demonstrate
De-escalation management
Crisis intervention training to supplement the de-escalation techniques with a focus on mental health populations
Components of rape aggression defense training will be taught to offer realistic self-defense tactics and techniques
35
What to Expect
A holistic approach to reducing both the risk and anxiety surrounding violence in healthcare
Excellent supplement to existing safety programs already in place at your organizations
Offered at no cost to Missouri HRET-HIIN hospitals
Audience
front line staff in all care units (ED critical care and medical-surgical units)
safety and security personnel36
Locations and Times
Workplace safety
Blue Springs
ndash April 11 2018 at the Courtyard Marriott ndash Adams Pointe Conference Center
Springfield
ndash April 25 2018 at the Oasis Hotel and Convention Center
St Charles
ndash May 2 2018 at the Embassy Suites Hotel
Cape Girardeau
ndash May 9 2018 at the Drury Plaza Hotel Conference Center
37
HIIN Project Updates
38
Data Due Dates mdash HIIN Project Year 2
39
MHA ldquoZero Heroesrdquo Club
MHA congratulates the following HIIN-participating hospitals with the most zero harm measures reported These organizations have either achieved andor sustained a zero rate of harm and are in the top 10 percent of HIIN-participating hospitals Congratulations to the ldquoZero Herosrdquo for the month of September
Carroll County Memorial Hospital
Ellett Memorial Hospital
Harrison County Community Hospital
Iron County Medical Center
Osage Beach Center for Cognitive Disorders
Pike County Memorial Hospital
Southeast Health Center of Ripley County
Sullivan County Memorial Hospital
40
AHArsquos IT department investigated the emails and discovered they were generated by groups from Germany and Switzerland AHA recommends that your IT department block emails from these two countries unless you do business with them
SPAM Email from HEN or HIIN Finance mdash PLEASE IGNORE
If you receive an email asking you to pay your invoice via a link please ignore and permanently delete Do not click on the link in the email The email may come from different email addresses but is titled as HENHIIN Finance or HRET HIIN similar to what is pictured below
41
Hospital Leadership and Quality Assessment Tool
The tool measures board members C-suite executives and managementsupervisors on how well they are implementing evidence-based practices shown to support a culture of safety and high performance in clinical quality measures
No front-line staff survey component
Survey content
FAQ
42
HLQAT Survey
MHA is providing this complimentary opportunity for all HIIN hospitals to access and utilize this survey
Two options
Phase I mdash Completed
Phase II mdash April through August 2018
ndash Available to all HIIN hospitals mdash previous participation not
required
ndash Phase I hospitals may participate in phase II if desired
ndash Intent to participate materials will be sent to HIIN contacts soon
43
Qualaris Audit Tool Projects
Hand Hygiene
Culture of Safety Rounding
Sepsis
ReadmissionsCare Transitions
44
Qualaris mdash New Tools
Qualaris has new tools to assist users with coordinating successful improvement projects
Tracking project outcomes alongside process measures
Real-time dashboards inclusive of both outcomes and process measures
Documenting PDSAs
Click here to view the Qualaris improvement projects and outcomes demo
These tools require a short setup webinar session with Qualaris
Readmission Immersion Project participants should contact supportqualariscom
Use the Qualaris virtual chat support for next steps
45
LEAN Six Sigma Green Belt Project
Project launching mdashMarch 13 2018 through November 30 2018
Hospitals committed mdash20
Topic-focused
Patient throughput
ICU harm reduction
Errors in medication reconciliation
46
Capital Region Medical Center
Carroll County Memorial Hospital
Cass Regional Medical Center
Cox Medical Center
Fitzgibbon Hospital
Golden Valley Memorial Healthcare
Hannibal Regional Hospital
Lafayette Regional Health Center
Lake Regional Health System
Liberty Hospital
North Kansas City Hospital
Ozark Medical Center
Perry County Memorial Hospital
Saint Lukes Health System
Saint Lukes Hospital Kansas City
Scotland County Hospital
Southeast Missouri Hospital
St Marys Medical Center
Ste Genevieve County Memorial Hospital
Western Missouri Medical Center
NHSN Reporting Facilities
The January 23rd release of the NHSN 881 application will introduce an updated NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled in NHSN prior to December 2 2017 Facilities that enrolled in NHSN on or after December 2 2017 have already accessed this new Consent and will not need to accept it again if they have already done so
Primary Contacts or Facility Administrators should agree to this updated Consent form for each component by April 14th 2018 or risk losing access to NHSN
An alert will appear on all NHSN component home pages and primary contacts and facility administrators will receive an email notification
Additional information including Frequently Asked Questions and the updated NHSN purposes are available on CDCs NHSN website If you have any questions please send an email to NHSNcdcgov with the subject line ldquoNHSN Reconsentrdquo
47
NHSN Reporting Facilities
The NHSN team has published informational guidance on our website to assist users with completion of the updated NHSN Agreement to Participate and Consent A 5-minute video informs users of the new Consent purposes and the simple process for accepting the Consent electronically Furthermore a step-by-step guidance document provides detailed instructions and screen shots for what Facility Administrators and Primary Contacts can expect to see when they begin the re-consent process in the NHSN application A link to the video and the guidance document can both be found in the FAQs About NHSNrsquos Agreement to Participate and Consent
48
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
Missouri Harm Dashboard
All Missouri acute care hospitals
Excludes rehab psych LTAC womenrsquos childrens specialty veteransmilitary
Distributed to CEOs quarterly
2017 Q4 dashboard was distributed at district council last week
Targeted education materials to be sent at the leadership level
31
Missouri Harm Dashboard
Includes NHSN data only
Measuring improvement of rates
Most recent SIR will be shown on dashboard
Measuring improvement over state target
Calendar year 2016 baseline
Data will be pulled quarterly
2017 Q4 distributed March 2018
2018 Q1 will be distributed June 2018
32
33
HIIN Regional Boot Camps
To Increase Workersrsquo Safety
34
What to Expect
Attendees will be taught and have the opportunity to demonstrate
De-escalation management
Crisis intervention training to supplement the de-escalation techniques with a focus on mental health populations
Components of rape aggression defense training will be taught to offer realistic self-defense tactics and techniques
35
What to Expect
A holistic approach to reducing both the risk and anxiety surrounding violence in healthcare
Excellent supplement to existing safety programs already in place at your organizations
Offered at no cost to Missouri HRET-HIIN hospitals
Audience
front line staff in all care units (ED critical care and medical-surgical units)
safety and security personnel36
Locations and Times
Workplace safety
Blue Springs
ndash April 11 2018 at the Courtyard Marriott ndash Adams Pointe Conference Center
Springfield
ndash April 25 2018 at the Oasis Hotel and Convention Center
St Charles
ndash May 2 2018 at the Embassy Suites Hotel
Cape Girardeau
ndash May 9 2018 at the Drury Plaza Hotel Conference Center
37
HIIN Project Updates
38
Data Due Dates mdash HIIN Project Year 2
39
MHA ldquoZero Heroesrdquo Club
MHA congratulates the following HIIN-participating hospitals with the most zero harm measures reported These organizations have either achieved andor sustained a zero rate of harm and are in the top 10 percent of HIIN-participating hospitals Congratulations to the ldquoZero Herosrdquo for the month of September
Carroll County Memorial Hospital
Ellett Memorial Hospital
Harrison County Community Hospital
Iron County Medical Center
Osage Beach Center for Cognitive Disorders
Pike County Memorial Hospital
Southeast Health Center of Ripley County
Sullivan County Memorial Hospital
40
AHArsquos IT department investigated the emails and discovered they were generated by groups from Germany and Switzerland AHA recommends that your IT department block emails from these two countries unless you do business with them
SPAM Email from HEN or HIIN Finance mdash PLEASE IGNORE
If you receive an email asking you to pay your invoice via a link please ignore and permanently delete Do not click on the link in the email The email may come from different email addresses but is titled as HENHIIN Finance or HRET HIIN similar to what is pictured below
41
Hospital Leadership and Quality Assessment Tool
The tool measures board members C-suite executives and managementsupervisors on how well they are implementing evidence-based practices shown to support a culture of safety and high performance in clinical quality measures
No front-line staff survey component
Survey content
FAQ
42
HLQAT Survey
MHA is providing this complimentary opportunity for all HIIN hospitals to access and utilize this survey
Two options
Phase I mdash Completed
Phase II mdash April through August 2018
ndash Available to all HIIN hospitals mdash previous participation not
required
ndash Phase I hospitals may participate in phase II if desired
ndash Intent to participate materials will be sent to HIIN contacts soon
43
Qualaris Audit Tool Projects
Hand Hygiene
Culture of Safety Rounding
Sepsis
ReadmissionsCare Transitions
44
Qualaris mdash New Tools
Qualaris has new tools to assist users with coordinating successful improvement projects
Tracking project outcomes alongside process measures
Real-time dashboards inclusive of both outcomes and process measures
Documenting PDSAs
Click here to view the Qualaris improvement projects and outcomes demo
These tools require a short setup webinar session with Qualaris
Readmission Immersion Project participants should contact supportqualariscom
Use the Qualaris virtual chat support for next steps
45
LEAN Six Sigma Green Belt Project
Project launching mdashMarch 13 2018 through November 30 2018
Hospitals committed mdash20
Topic-focused
Patient throughput
ICU harm reduction
Errors in medication reconciliation
46
Capital Region Medical Center
Carroll County Memorial Hospital
Cass Regional Medical Center
Cox Medical Center
Fitzgibbon Hospital
Golden Valley Memorial Healthcare
Hannibal Regional Hospital
Lafayette Regional Health Center
Lake Regional Health System
Liberty Hospital
North Kansas City Hospital
Ozark Medical Center
Perry County Memorial Hospital
Saint Lukes Health System
Saint Lukes Hospital Kansas City
Scotland County Hospital
Southeast Missouri Hospital
St Marys Medical Center
Ste Genevieve County Memorial Hospital
Western Missouri Medical Center
NHSN Reporting Facilities
The January 23rd release of the NHSN 881 application will introduce an updated NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled in NHSN prior to December 2 2017 Facilities that enrolled in NHSN on or after December 2 2017 have already accessed this new Consent and will not need to accept it again if they have already done so
Primary Contacts or Facility Administrators should agree to this updated Consent form for each component by April 14th 2018 or risk losing access to NHSN
An alert will appear on all NHSN component home pages and primary contacts and facility administrators will receive an email notification
Additional information including Frequently Asked Questions and the updated NHSN purposes are available on CDCs NHSN website If you have any questions please send an email to NHSNcdcgov with the subject line ldquoNHSN Reconsentrdquo
47
NHSN Reporting Facilities
The NHSN team has published informational guidance on our website to assist users with completion of the updated NHSN Agreement to Participate and Consent A 5-minute video informs users of the new Consent purposes and the simple process for accepting the Consent electronically Furthermore a step-by-step guidance document provides detailed instructions and screen shots for what Facility Administrators and Primary Contacts can expect to see when they begin the re-consent process in the NHSN application A link to the video and the guidance document can both be found in the FAQs About NHSNrsquos Agreement to Participate and Consent
48
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
Missouri Harm Dashboard
Includes NHSN data only
Measuring improvement of rates
Most recent SIR will be shown on dashboard
Measuring improvement over state target
Calendar year 2016 baseline
Data will be pulled quarterly
2017 Q4 distributed March 2018
2018 Q1 will be distributed June 2018
32
33
HIIN Regional Boot Camps
To Increase Workersrsquo Safety
34
What to Expect
Attendees will be taught and have the opportunity to demonstrate
De-escalation management
Crisis intervention training to supplement the de-escalation techniques with a focus on mental health populations
Components of rape aggression defense training will be taught to offer realistic self-defense tactics and techniques
35
What to Expect
A holistic approach to reducing both the risk and anxiety surrounding violence in healthcare
Excellent supplement to existing safety programs already in place at your organizations
Offered at no cost to Missouri HRET-HIIN hospitals
Audience
front line staff in all care units (ED critical care and medical-surgical units)
safety and security personnel36
Locations and Times
Workplace safety
Blue Springs
ndash April 11 2018 at the Courtyard Marriott ndash Adams Pointe Conference Center
Springfield
ndash April 25 2018 at the Oasis Hotel and Convention Center
St Charles
ndash May 2 2018 at the Embassy Suites Hotel
Cape Girardeau
ndash May 9 2018 at the Drury Plaza Hotel Conference Center
37
HIIN Project Updates
38
Data Due Dates mdash HIIN Project Year 2
39
MHA ldquoZero Heroesrdquo Club
MHA congratulates the following HIIN-participating hospitals with the most zero harm measures reported These organizations have either achieved andor sustained a zero rate of harm and are in the top 10 percent of HIIN-participating hospitals Congratulations to the ldquoZero Herosrdquo for the month of September
Carroll County Memorial Hospital
Ellett Memorial Hospital
Harrison County Community Hospital
Iron County Medical Center
Osage Beach Center for Cognitive Disorders
Pike County Memorial Hospital
Southeast Health Center of Ripley County
Sullivan County Memorial Hospital
40
AHArsquos IT department investigated the emails and discovered they were generated by groups from Germany and Switzerland AHA recommends that your IT department block emails from these two countries unless you do business with them
SPAM Email from HEN or HIIN Finance mdash PLEASE IGNORE
If you receive an email asking you to pay your invoice via a link please ignore and permanently delete Do not click on the link in the email The email may come from different email addresses but is titled as HENHIIN Finance or HRET HIIN similar to what is pictured below
41
Hospital Leadership and Quality Assessment Tool
The tool measures board members C-suite executives and managementsupervisors on how well they are implementing evidence-based practices shown to support a culture of safety and high performance in clinical quality measures
No front-line staff survey component
Survey content
FAQ
42
HLQAT Survey
MHA is providing this complimentary opportunity for all HIIN hospitals to access and utilize this survey
Two options
Phase I mdash Completed
Phase II mdash April through August 2018
ndash Available to all HIIN hospitals mdash previous participation not
required
ndash Phase I hospitals may participate in phase II if desired
ndash Intent to participate materials will be sent to HIIN contacts soon
43
Qualaris Audit Tool Projects
Hand Hygiene
Culture of Safety Rounding
Sepsis
ReadmissionsCare Transitions
44
Qualaris mdash New Tools
Qualaris has new tools to assist users with coordinating successful improvement projects
Tracking project outcomes alongside process measures
Real-time dashboards inclusive of both outcomes and process measures
Documenting PDSAs
Click here to view the Qualaris improvement projects and outcomes demo
These tools require a short setup webinar session with Qualaris
Readmission Immersion Project participants should contact supportqualariscom
Use the Qualaris virtual chat support for next steps
45
LEAN Six Sigma Green Belt Project
Project launching mdashMarch 13 2018 through November 30 2018
Hospitals committed mdash20
Topic-focused
Patient throughput
ICU harm reduction
Errors in medication reconciliation
46
Capital Region Medical Center
Carroll County Memorial Hospital
Cass Regional Medical Center
Cox Medical Center
Fitzgibbon Hospital
Golden Valley Memorial Healthcare
Hannibal Regional Hospital
Lafayette Regional Health Center
Lake Regional Health System
Liberty Hospital
North Kansas City Hospital
Ozark Medical Center
Perry County Memorial Hospital
Saint Lukes Health System
Saint Lukes Hospital Kansas City
Scotland County Hospital
Southeast Missouri Hospital
St Marys Medical Center
Ste Genevieve County Memorial Hospital
Western Missouri Medical Center
NHSN Reporting Facilities
The January 23rd release of the NHSN 881 application will introduce an updated NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled in NHSN prior to December 2 2017 Facilities that enrolled in NHSN on or after December 2 2017 have already accessed this new Consent and will not need to accept it again if they have already done so
Primary Contacts or Facility Administrators should agree to this updated Consent form for each component by April 14th 2018 or risk losing access to NHSN
An alert will appear on all NHSN component home pages and primary contacts and facility administrators will receive an email notification
Additional information including Frequently Asked Questions and the updated NHSN purposes are available on CDCs NHSN website If you have any questions please send an email to NHSNcdcgov with the subject line ldquoNHSN Reconsentrdquo
47
NHSN Reporting Facilities
The NHSN team has published informational guidance on our website to assist users with completion of the updated NHSN Agreement to Participate and Consent A 5-minute video informs users of the new Consent purposes and the simple process for accepting the Consent electronically Furthermore a step-by-step guidance document provides detailed instructions and screen shots for what Facility Administrators and Primary Contacts can expect to see when they begin the re-consent process in the NHSN application A link to the video and the guidance document can both be found in the FAQs About NHSNrsquos Agreement to Participate and Consent
48
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
33
HIIN Regional Boot Camps
To Increase Workersrsquo Safety
34
What to Expect
Attendees will be taught and have the opportunity to demonstrate
De-escalation management
Crisis intervention training to supplement the de-escalation techniques with a focus on mental health populations
Components of rape aggression defense training will be taught to offer realistic self-defense tactics and techniques
35
What to Expect
A holistic approach to reducing both the risk and anxiety surrounding violence in healthcare
Excellent supplement to existing safety programs already in place at your organizations
Offered at no cost to Missouri HRET-HIIN hospitals
Audience
front line staff in all care units (ED critical care and medical-surgical units)
safety and security personnel36
Locations and Times
Workplace safety
Blue Springs
ndash April 11 2018 at the Courtyard Marriott ndash Adams Pointe Conference Center
Springfield
ndash April 25 2018 at the Oasis Hotel and Convention Center
St Charles
ndash May 2 2018 at the Embassy Suites Hotel
Cape Girardeau
ndash May 9 2018 at the Drury Plaza Hotel Conference Center
37
HIIN Project Updates
38
Data Due Dates mdash HIIN Project Year 2
39
MHA ldquoZero Heroesrdquo Club
MHA congratulates the following HIIN-participating hospitals with the most zero harm measures reported These organizations have either achieved andor sustained a zero rate of harm and are in the top 10 percent of HIIN-participating hospitals Congratulations to the ldquoZero Herosrdquo for the month of September
Carroll County Memorial Hospital
Ellett Memorial Hospital
Harrison County Community Hospital
Iron County Medical Center
Osage Beach Center for Cognitive Disorders
Pike County Memorial Hospital
Southeast Health Center of Ripley County
Sullivan County Memorial Hospital
40
AHArsquos IT department investigated the emails and discovered they were generated by groups from Germany and Switzerland AHA recommends that your IT department block emails from these two countries unless you do business with them
SPAM Email from HEN or HIIN Finance mdash PLEASE IGNORE
If you receive an email asking you to pay your invoice via a link please ignore and permanently delete Do not click on the link in the email The email may come from different email addresses but is titled as HENHIIN Finance or HRET HIIN similar to what is pictured below
41
Hospital Leadership and Quality Assessment Tool
The tool measures board members C-suite executives and managementsupervisors on how well they are implementing evidence-based practices shown to support a culture of safety and high performance in clinical quality measures
No front-line staff survey component
Survey content
FAQ
42
HLQAT Survey
MHA is providing this complimentary opportunity for all HIIN hospitals to access and utilize this survey
Two options
Phase I mdash Completed
Phase II mdash April through August 2018
ndash Available to all HIIN hospitals mdash previous participation not
required
ndash Phase I hospitals may participate in phase II if desired
ndash Intent to participate materials will be sent to HIIN contacts soon
43
Qualaris Audit Tool Projects
Hand Hygiene
Culture of Safety Rounding
Sepsis
ReadmissionsCare Transitions
44
Qualaris mdash New Tools
Qualaris has new tools to assist users with coordinating successful improvement projects
Tracking project outcomes alongside process measures
Real-time dashboards inclusive of both outcomes and process measures
Documenting PDSAs
Click here to view the Qualaris improvement projects and outcomes demo
These tools require a short setup webinar session with Qualaris
Readmission Immersion Project participants should contact supportqualariscom
Use the Qualaris virtual chat support for next steps
45
LEAN Six Sigma Green Belt Project
Project launching mdashMarch 13 2018 through November 30 2018
Hospitals committed mdash20
Topic-focused
Patient throughput
ICU harm reduction
Errors in medication reconciliation
46
Capital Region Medical Center
Carroll County Memorial Hospital
Cass Regional Medical Center
Cox Medical Center
Fitzgibbon Hospital
Golden Valley Memorial Healthcare
Hannibal Regional Hospital
Lafayette Regional Health Center
Lake Regional Health System
Liberty Hospital
North Kansas City Hospital
Ozark Medical Center
Perry County Memorial Hospital
Saint Lukes Health System
Saint Lukes Hospital Kansas City
Scotland County Hospital
Southeast Missouri Hospital
St Marys Medical Center
Ste Genevieve County Memorial Hospital
Western Missouri Medical Center
NHSN Reporting Facilities
The January 23rd release of the NHSN 881 application will introduce an updated NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled in NHSN prior to December 2 2017 Facilities that enrolled in NHSN on or after December 2 2017 have already accessed this new Consent and will not need to accept it again if they have already done so
Primary Contacts or Facility Administrators should agree to this updated Consent form for each component by April 14th 2018 or risk losing access to NHSN
An alert will appear on all NHSN component home pages and primary contacts and facility administrators will receive an email notification
Additional information including Frequently Asked Questions and the updated NHSN purposes are available on CDCs NHSN website If you have any questions please send an email to NHSNcdcgov with the subject line ldquoNHSN Reconsentrdquo
47
NHSN Reporting Facilities
The NHSN team has published informational guidance on our website to assist users with completion of the updated NHSN Agreement to Participate and Consent A 5-minute video informs users of the new Consent purposes and the simple process for accepting the Consent electronically Furthermore a step-by-step guidance document provides detailed instructions and screen shots for what Facility Administrators and Primary Contacts can expect to see when they begin the re-consent process in the NHSN application A link to the video and the guidance document can both be found in the FAQs About NHSNrsquos Agreement to Participate and Consent
48
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
HIIN Regional Boot Camps
To Increase Workersrsquo Safety
34
What to Expect
Attendees will be taught and have the opportunity to demonstrate
De-escalation management
Crisis intervention training to supplement the de-escalation techniques with a focus on mental health populations
Components of rape aggression defense training will be taught to offer realistic self-defense tactics and techniques
35
What to Expect
A holistic approach to reducing both the risk and anxiety surrounding violence in healthcare
Excellent supplement to existing safety programs already in place at your organizations
Offered at no cost to Missouri HRET-HIIN hospitals
Audience
front line staff in all care units (ED critical care and medical-surgical units)
safety and security personnel36
Locations and Times
Workplace safety
Blue Springs
ndash April 11 2018 at the Courtyard Marriott ndash Adams Pointe Conference Center
Springfield
ndash April 25 2018 at the Oasis Hotel and Convention Center
St Charles
ndash May 2 2018 at the Embassy Suites Hotel
Cape Girardeau
ndash May 9 2018 at the Drury Plaza Hotel Conference Center
37
HIIN Project Updates
38
Data Due Dates mdash HIIN Project Year 2
39
MHA ldquoZero Heroesrdquo Club
MHA congratulates the following HIIN-participating hospitals with the most zero harm measures reported These organizations have either achieved andor sustained a zero rate of harm and are in the top 10 percent of HIIN-participating hospitals Congratulations to the ldquoZero Herosrdquo for the month of September
Carroll County Memorial Hospital
Ellett Memorial Hospital
Harrison County Community Hospital
Iron County Medical Center
Osage Beach Center for Cognitive Disorders
Pike County Memorial Hospital
Southeast Health Center of Ripley County
Sullivan County Memorial Hospital
40
AHArsquos IT department investigated the emails and discovered they were generated by groups from Germany and Switzerland AHA recommends that your IT department block emails from these two countries unless you do business with them
SPAM Email from HEN or HIIN Finance mdash PLEASE IGNORE
If you receive an email asking you to pay your invoice via a link please ignore and permanently delete Do not click on the link in the email The email may come from different email addresses but is titled as HENHIIN Finance or HRET HIIN similar to what is pictured below
41
Hospital Leadership and Quality Assessment Tool
The tool measures board members C-suite executives and managementsupervisors on how well they are implementing evidence-based practices shown to support a culture of safety and high performance in clinical quality measures
No front-line staff survey component
Survey content
FAQ
42
HLQAT Survey
MHA is providing this complimentary opportunity for all HIIN hospitals to access and utilize this survey
Two options
Phase I mdash Completed
Phase II mdash April through August 2018
ndash Available to all HIIN hospitals mdash previous participation not
required
ndash Phase I hospitals may participate in phase II if desired
ndash Intent to participate materials will be sent to HIIN contacts soon
43
Qualaris Audit Tool Projects
Hand Hygiene
Culture of Safety Rounding
Sepsis
ReadmissionsCare Transitions
44
Qualaris mdash New Tools
Qualaris has new tools to assist users with coordinating successful improvement projects
Tracking project outcomes alongside process measures
Real-time dashboards inclusive of both outcomes and process measures
Documenting PDSAs
Click here to view the Qualaris improvement projects and outcomes demo
These tools require a short setup webinar session with Qualaris
Readmission Immersion Project participants should contact supportqualariscom
Use the Qualaris virtual chat support for next steps
45
LEAN Six Sigma Green Belt Project
Project launching mdashMarch 13 2018 through November 30 2018
Hospitals committed mdash20
Topic-focused
Patient throughput
ICU harm reduction
Errors in medication reconciliation
46
Capital Region Medical Center
Carroll County Memorial Hospital
Cass Regional Medical Center
Cox Medical Center
Fitzgibbon Hospital
Golden Valley Memorial Healthcare
Hannibal Regional Hospital
Lafayette Regional Health Center
Lake Regional Health System
Liberty Hospital
North Kansas City Hospital
Ozark Medical Center
Perry County Memorial Hospital
Saint Lukes Health System
Saint Lukes Hospital Kansas City
Scotland County Hospital
Southeast Missouri Hospital
St Marys Medical Center
Ste Genevieve County Memorial Hospital
Western Missouri Medical Center
NHSN Reporting Facilities
The January 23rd release of the NHSN 881 application will introduce an updated NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled in NHSN prior to December 2 2017 Facilities that enrolled in NHSN on or after December 2 2017 have already accessed this new Consent and will not need to accept it again if they have already done so
Primary Contacts or Facility Administrators should agree to this updated Consent form for each component by April 14th 2018 or risk losing access to NHSN
An alert will appear on all NHSN component home pages and primary contacts and facility administrators will receive an email notification
Additional information including Frequently Asked Questions and the updated NHSN purposes are available on CDCs NHSN website If you have any questions please send an email to NHSNcdcgov with the subject line ldquoNHSN Reconsentrdquo
47
NHSN Reporting Facilities
The NHSN team has published informational guidance on our website to assist users with completion of the updated NHSN Agreement to Participate and Consent A 5-minute video informs users of the new Consent purposes and the simple process for accepting the Consent electronically Furthermore a step-by-step guidance document provides detailed instructions and screen shots for what Facility Administrators and Primary Contacts can expect to see when they begin the re-consent process in the NHSN application A link to the video and the guidance document can both be found in the FAQs About NHSNrsquos Agreement to Participate and Consent
48
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
What to Expect
Attendees will be taught and have the opportunity to demonstrate
De-escalation management
Crisis intervention training to supplement the de-escalation techniques with a focus on mental health populations
Components of rape aggression defense training will be taught to offer realistic self-defense tactics and techniques
35
What to Expect
A holistic approach to reducing both the risk and anxiety surrounding violence in healthcare
Excellent supplement to existing safety programs already in place at your organizations
Offered at no cost to Missouri HRET-HIIN hospitals
Audience
front line staff in all care units (ED critical care and medical-surgical units)
safety and security personnel36
Locations and Times
Workplace safety
Blue Springs
ndash April 11 2018 at the Courtyard Marriott ndash Adams Pointe Conference Center
Springfield
ndash April 25 2018 at the Oasis Hotel and Convention Center
St Charles
ndash May 2 2018 at the Embassy Suites Hotel
Cape Girardeau
ndash May 9 2018 at the Drury Plaza Hotel Conference Center
37
HIIN Project Updates
38
Data Due Dates mdash HIIN Project Year 2
39
MHA ldquoZero Heroesrdquo Club
MHA congratulates the following HIIN-participating hospitals with the most zero harm measures reported These organizations have either achieved andor sustained a zero rate of harm and are in the top 10 percent of HIIN-participating hospitals Congratulations to the ldquoZero Herosrdquo for the month of September
Carroll County Memorial Hospital
Ellett Memorial Hospital
Harrison County Community Hospital
Iron County Medical Center
Osage Beach Center for Cognitive Disorders
Pike County Memorial Hospital
Southeast Health Center of Ripley County
Sullivan County Memorial Hospital
40
AHArsquos IT department investigated the emails and discovered they were generated by groups from Germany and Switzerland AHA recommends that your IT department block emails from these two countries unless you do business with them
SPAM Email from HEN or HIIN Finance mdash PLEASE IGNORE
If you receive an email asking you to pay your invoice via a link please ignore and permanently delete Do not click on the link in the email The email may come from different email addresses but is titled as HENHIIN Finance or HRET HIIN similar to what is pictured below
41
Hospital Leadership and Quality Assessment Tool
The tool measures board members C-suite executives and managementsupervisors on how well they are implementing evidence-based practices shown to support a culture of safety and high performance in clinical quality measures
No front-line staff survey component
Survey content
FAQ
42
HLQAT Survey
MHA is providing this complimentary opportunity for all HIIN hospitals to access and utilize this survey
Two options
Phase I mdash Completed
Phase II mdash April through August 2018
ndash Available to all HIIN hospitals mdash previous participation not
required
ndash Phase I hospitals may participate in phase II if desired
ndash Intent to participate materials will be sent to HIIN contacts soon
43
Qualaris Audit Tool Projects
Hand Hygiene
Culture of Safety Rounding
Sepsis
ReadmissionsCare Transitions
44
Qualaris mdash New Tools
Qualaris has new tools to assist users with coordinating successful improvement projects
Tracking project outcomes alongside process measures
Real-time dashboards inclusive of both outcomes and process measures
Documenting PDSAs
Click here to view the Qualaris improvement projects and outcomes demo
These tools require a short setup webinar session with Qualaris
Readmission Immersion Project participants should contact supportqualariscom
Use the Qualaris virtual chat support for next steps
45
LEAN Six Sigma Green Belt Project
Project launching mdashMarch 13 2018 through November 30 2018
Hospitals committed mdash20
Topic-focused
Patient throughput
ICU harm reduction
Errors in medication reconciliation
46
Capital Region Medical Center
Carroll County Memorial Hospital
Cass Regional Medical Center
Cox Medical Center
Fitzgibbon Hospital
Golden Valley Memorial Healthcare
Hannibal Regional Hospital
Lafayette Regional Health Center
Lake Regional Health System
Liberty Hospital
North Kansas City Hospital
Ozark Medical Center
Perry County Memorial Hospital
Saint Lukes Health System
Saint Lukes Hospital Kansas City
Scotland County Hospital
Southeast Missouri Hospital
St Marys Medical Center
Ste Genevieve County Memorial Hospital
Western Missouri Medical Center
NHSN Reporting Facilities
The January 23rd release of the NHSN 881 application will introduce an updated NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled in NHSN prior to December 2 2017 Facilities that enrolled in NHSN on or after December 2 2017 have already accessed this new Consent and will not need to accept it again if they have already done so
Primary Contacts or Facility Administrators should agree to this updated Consent form for each component by April 14th 2018 or risk losing access to NHSN
An alert will appear on all NHSN component home pages and primary contacts and facility administrators will receive an email notification
Additional information including Frequently Asked Questions and the updated NHSN purposes are available on CDCs NHSN website If you have any questions please send an email to NHSNcdcgov with the subject line ldquoNHSN Reconsentrdquo
47
NHSN Reporting Facilities
The NHSN team has published informational guidance on our website to assist users with completion of the updated NHSN Agreement to Participate and Consent A 5-minute video informs users of the new Consent purposes and the simple process for accepting the Consent electronically Furthermore a step-by-step guidance document provides detailed instructions and screen shots for what Facility Administrators and Primary Contacts can expect to see when they begin the re-consent process in the NHSN application A link to the video and the guidance document can both be found in the FAQs About NHSNrsquos Agreement to Participate and Consent
48
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
What to Expect
A holistic approach to reducing both the risk and anxiety surrounding violence in healthcare
Excellent supplement to existing safety programs already in place at your organizations
Offered at no cost to Missouri HRET-HIIN hospitals
Audience
front line staff in all care units (ED critical care and medical-surgical units)
safety and security personnel36
Locations and Times
Workplace safety
Blue Springs
ndash April 11 2018 at the Courtyard Marriott ndash Adams Pointe Conference Center
Springfield
ndash April 25 2018 at the Oasis Hotel and Convention Center
St Charles
ndash May 2 2018 at the Embassy Suites Hotel
Cape Girardeau
ndash May 9 2018 at the Drury Plaza Hotel Conference Center
37
HIIN Project Updates
38
Data Due Dates mdash HIIN Project Year 2
39
MHA ldquoZero Heroesrdquo Club
MHA congratulates the following HIIN-participating hospitals with the most zero harm measures reported These organizations have either achieved andor sustained a zero rate of harm and are in the top 10 percent of HIIN-participating hospitals Congratulations to the ldquoZero Herosrdquo for the month of September
Carroll County Memorial Hospital
Ellett Memorial Hospital
Harrison County Community Hospital
Iron County Medical Center
Osage Beach Center for Cognitive Disorders
Pike County Memorial Hospital
Southeast Health Center of Ripley County
Sullivan County Memorial Hospital
40
AHArsquos IT department investigated the emails and discovered they were generated by groups from Germany and Switzerland AHA recommends that your IT department block emails from these two countries unless you do business with them
SPAM Email from HEN or HIIN Finance mdash PLEASE IGNORE
If you receive an email asking you to pay your invoice via a link please ignore and permanently delete Do not click on the link in the email The email may come from different email addresses but is titled as HENHIIN Finance or HRET HIIN similar to what is pictured below
41
Hospital Leadership and Quality Assessment Tool
The tool measures board members C-suite executives and managementsupervisors on how well they are implementing evidence-based practices shown to support a culture of safety and high performance in clinical quality measures
No front-line staff survey component
Survey content
FAQ
42
HLQAT Survey
MHA is providing this complimentary opportunity for all HIIN hospitals to access and utilize this survey
Two options
Phase I mdash Completed
Phase II mdash April through August 2018
ndash Available to all HIIN hospitals mdash previous participation not
required
ndash Phase I hospitals may participate in phase II if desired
ndash Intent to participate materials will be sent to HIIN contacts soon
43
Qualaris Audit Tool Projects
Hand Hygiene
Culture of Safety Rounding
Sepsis
ReadmissionsCare Transitions
44
Qualaris mdash New Tools
Qualaris has new tools to assist users with coordinating successful improvement projects
Tracking project outcomes alongside process measures
Real-time dashboards inclusive of both outcomes and process measures
Documenting PDSAs
Click here to view the Qualaris improvement projects and outcomes demo
These tools require a short setup webinar session with Qualaris
Readmission Immersion Project participants should contact supportqualariscom
Use the Qualaris virtual chat support for next steps
45
LEAN Six Sigma Green Belt Project
Project launching mdashMarch 13 2018 through November 30 2018
Hospitals committed mdash20
Topic-focused
Patient throughput
ICU harm reduction
Errors in medication reconciliation
46
Capital Region Medical Center
Carroll County Memorial Hospital
Cass Regional Medical Center
Cox Medical Center
Fitzgibbon Hospital
Golden Valley Memorial Healthcare
Hannibal Regional Hospital
Lafayette Regional Health Center
Lake Regional Health System
Liberty Hospital
North Kansas City Hospital
Ozark Medical Center
Perry County Memorial Hospital
Saint Lukes Health System
Saint Lukes Hospital Kansas City
Scotland County Hospital
Southeast Missouri Hospital
St Marys Medical Center
Ste Genevieve County Memorial Hospital
Western Missouri Medical Center
NHSN Reporting Facilities
The January 23rd release of the NHSN 881 application will introduce an updated NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled in NHSN prior to December 2 2017 Facilities that enrolled in NHSN on or after December 2 2017 have already accessed this new Consent and will not need to accept it again if they have already done so
Primary Contacts or Facility Administrators should agree to this updated Consent form for each component by April 14th 2018 or risk losing access to NHSN
An alert will appear on all NHSN component home pages and primary contacts and facility administrators will receive an email notification
Additional information including Frequently Asked Questions and the updated NHSN purposes are available on CDCs NHSN website If you have any questions please send an email to NHSNcdcgov with the subject line ldquoNHSN Reconsentrdquo
47
NHSN Reporting Facilities
The NHSN team has published informational guidance on our website to assist users with completion of the updated NHSN Agreement to Participate and Consent A 5-minute video informs users of the new Consent purposes and the simple process for accepting the Consent electronically Furthermore a step-by-step guidance document provides detailed instructions and screen shots for what Facility Administrators and Primary Contacts can expect to see when they begin the re-consent process in the NHSN application A link to the video and the guidance document can both be found in the FAQs About NHSNrsquos Agreement to Participate and Consent
48
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
Locations and Times
Workplace safety
Blue Springs
ndash April 11 2018 at the Courtyard Marriott ndash Adams Pointe Conference Center
Springfield
ndash April 25 2018 at the Oasis Hotel and Convention Center
St Charles
ndash May 2 2018 at the Embassy Suites Hotel
Cape Girardeau
ndash May 9 2018 at the Drury Plaza Hotel Conference Center
37
HIIN Project Updates
38
Data Due Dates mdash HIIN Project Year 2
39
MHA ldquoZero Heroesrdquo Club
MHA congratulates the following HIIN-participating hospitals with the most zero harm measures reported These organizations have either achieved andor sustained a zero rate of harm and are in the top 10 percent of HIIN-participating hospitals Congratulations to the ldquoZero Herosrdquo for the month of September
Carroll County Memorial Hospital
Ellett Memorial Hospital
Harrison County Community Hospital
Iron County Medical Center
Osage Beach Center for Cognitive Disorders
Pike County Memorial Hospital
Southeast Health Center of Ripley County
Sullivan County Memorial Hospital
40
AHArsquos IT department investigated the emails and discovered they were generated by groups from Germany and Switzerland AHA recommends that your IT department block emails from these two countries unless you do business with them
SPAM Email from HEN or HIIN Finance mdash PLEASE IGNORE
If you receive an email asking you to pay your invoice via a link please ignore and permanently delete Do not click on the link in the email The email may come from different email addresses but is titled as HENHIIN Finance or HRET HIIN similar to what is pictured below
41
Hospital Leadership and Quality Assessment Tool
The tool measures board members C-suite executives and managementsupervisors on how well they are implementing evidence-based practices shown to support a culture of safety and high performance in clinical quality measures
No front-line staff survey component
Survey content
FAQ
42
HLQAT Survey
MHA is providing this complimentary opportunity for all HIIN hospitals to access and utilize this survey
Two options
Phase I mdash Completed
Phase II mdash April through August 2018
ndash Available to all HIIN hospitals mdash previous participation not
required
ndash Phase I hospitals may participate in phase II if desired
ndash Intent to participate materials will be sent to HIIN contacts soon
43
Qualaris Audit Tool Projects
Hand Hygiene
Culture of Safety Rounding
Sepsis
ReadmissionsCare Transitions
44
Qualaris mdash New Tools
Qualaris has new tools to assist users with coordinating successful improvement projects
Tracking project outcomes alongside process measures
Real-time dashboards inclusive of both outcomes and process measures
Documenting PDSAs
Click here to view the Qualaris improvement projects and outcomes demo
These tools require a short setup webinar session with Qualaris
Readmission Immersion Project participants should contact supportqualariscom
Use the Qualaris virtual chat support for next steps
45
LEAN Six Sigma Green Belt Project
Project launching mdashMarch 13 2018 through November 30 2018
Hospitals committed mdash20
Topic-focused
Patient throughput
ICU harm reduction
Errors in medication reconciliation
46
Capital Region Medical Center
Carroll County Memorial Hospital
Cass Regional Medical Center
Cox Medical Center
Fitzgibbon Hospital
Golden Valley Memorial Healthcare
Hannibal Regional Hospital
Lafayette Regional Health Center
Lake Regional Health System
Liberty Hospital
North Kansas City Hospital
Ozark Medical Center
Perry County Memorial Hospital
Saint Lukes Health System
Saint Lukes Hospital Kansas City
Scotland County Hospital
Southeast Missouri Hospital
St Marys Medical Center
Ste Genevieve County Memorial Hospital
Western Missouri Medical Center
NHSN Reporting Facilities
The January 23rd release of the NHSN 881 application will introduce an updated NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled in NHSN prior to December 2 2017 Facilities that enrolled in NHSN on or after December 2 2017 have already accessed this new Consent and will not need to accept it again if they have already done so
Primary Contacts or Facility Administrators should agree to this updated Consent form for each component by April 14th 2018 or risk losing access to NHSN
An alert will appear on all NHSN component home pages and primary contacts and facility administrators will receive an email notification
Additional information including Frequently Asked Questions and the updated NHSN purposes are available on CDCs NHSN website If you have any questions please send an email to NHSNcdcgov with the subject line ldquoNHSN Reconsentrdquo
47
NHSN Reporting Facilities
The NHSN team has published informational guidance on our website to assist users with completion of the updated NHSN Agreement to Participate and Consent A 5-minute video informs users of the new Consent purposes and the simple process for accepting the Consent electronically Furthermore a step-by-step guidance document provides detailed instructions and screen shots for what Facility Administrators and Primary Contacts can expect to see when they begin the re-consent process in the NHSN application A link to the video and the guidance document can both be found in the FAQs About NHSNrsquos Agreement to Participate and Consent
48
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
HIIN Project Updates
38
Data Due Dates mdash HIIN Project Year 2
39
MHA ldquoZero Heroesrdquo Club
MHA congratulates the following HIIN-participating hospitals with the most zero harm measures reported These organizations have either achieved andor sustained a zero rate of harm and are in the top 10 percent of HIIN-participating hospitals Congratulations to the ldquoZero Herosrdquo for the month of September
Carroll County Memorial Hospital
Ellett Memorial Hospital
Harrison County Community Hospital
Iron County Medical Center
Osage Beach Center for Cognitive Disorders
Pike County Memorial Hospital
Southeast Health Center of Ripley County
Sullivan County Memorial Hospital
40
AHArsquos IT department investigated the emails and discovered they were generated by groups from Germany and Switzerland AHA recommends that your IT department block emails from these two countries unless you do business with them
SPAM Email from HEN or HIIN Finance mdash PLEASE IGNORE
If you receive an email asking you to pay your invoice via a link please ignore and permanently delete Do not click on the link in the email The email may come from different email addresses but is titled as HENHIIN Finance or HRET HIIN similar to what is pictured below
41
Hospital Leadership and Quality Assessment Tool
The tool measures board members C-suite executives and managementsupervisors on how well they are implementing evidence-based practices shown to support a culture of safety and high performance in clinical quality measures
No front-line staff survey component
Survey content
FAQ
42
HLQAT Survey
MHA is providing this complimentary opportunity for all HIIN hospitals to access and utilize this survey
Two options
Phase I mdash Completed
Phase II mdash April through August 2018
ndash Available to all HIIN hospitals mdash previous participation not
required
ndash Phase I hospitals may participate in phase II if desired
ndash Intent to participate materials will be sent to HIIN contacts soon
43
Qualaris Audit Tool Projects
Hand Hygiene
Culture of Safety Rounding
Sepsis
ReadmissionsCare Transitions
44
Qualaris mdash New Tools
Qualaris has new tools to assist users with coordinating successful improvement projects
Tracking project outcomes alongside process measures
Real-time dashboards inclusive of both outcomes and process measures
Documenting PDSAs
Click here to view the Qualaris improvement projects and outcomes demo
These tools require a short setup webinar session with Qualaris
Readmission Immersion Project participants should contact supportqualariscom
Use the Qualaris virtual chat support for next steps
45
LEAN Six Sigma Green Belt Project
Project launching mdashMarch 13 2018 through November 30 2018
Hospitals committed mdash20
Topic-focused
Patient throughput
ICU harm reduction
Errors in medication reconciliation
46
Capital Region Medical Center
Carroll County Memorial Hospital
Cass Regional Medical Center
Cox Medical Center
Fitzgibbon Hospital
Golden Valley Memorial Healthcare
Hannibal Regional Hospital
Lafayette Regional Health Center
Lake Regional Health System
Liberty Hospital
North Kansas City Hospital
Ozark Medical Center
Perry County Memorial Hospital
Saint Lukes Health System
Saint Lukes Hospital Kansas City
Scotland County Hospital
Southeast Missouri Hospital
St Marys Medical Center
Ste Genevieve County Memorial Hospital
Western Missouri Medical Center
NHSN Reporting Facilities
The January 23rd release of the NHSN 881 application will introduce an updated NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled in NHSN prior to December 2 2017 Facilities that enrolled in NHSN on or after December 2 2017 have already accessed this new Consent and will not need to accept it again if they have already done so
Primary Contacts or Facility Administrators should agree to this updated Consent form for each component by April 14th 2018 or risk losing access to NHSN
An alert will appear on all NHSN component home pages and primary contacts and facility administrators will receive an email notification
Additional information including Frequently Asked Questions and the updated NHSN purposes are available on CDCs NHSN website If you have any questions please send an email to NHSNcdcgov with the subject line ldquoNHSN Reconsentrdquo
47
NHSN Reporting Facilities
The NHSN team has published informational guidance on our website to assist users with completion of the updated NHSN Agreement to Participate and Consent A 5-minute video informs users of the new Consent purposes and the simple process for accepting the Consent electronically Furthermore a step-by-step guidance document provides detailed instructions and screen shots for what Facility Administrators and Primary Contacts can expect to see when they begin the re-consent process in the NHSN application A link to the video and the guidance document can both be found in the FAQs About NHSNrsquos Agreement to Participate and Consent
48
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
Data Due Dates mdash HIIN Project Year 2
39
MHA ldquoZero Heroesrdquo Club
MHA congratulates the following HIIN-participating hospitals with the most zero harm measures reported These organizations have either achieved andor sustained a zero rate of harm and are in the top 10 percent of HIIN-participating hospitals Congratulations to the ldquoZero Herosrdquo for the month of September
Carroll County Memorial Hospital
Ellett Memorial Hospital
Harrison County Community Hospital
Iron County Medical Center
Osage Beach Center for Cognitive Disorders
Pike County Memorial Hospital
Southeast Health Center of Ripley County
Sullivan County Memorial Hospital
40
AHArsquos IT department investigated the emails and discovered they were generated by groups from Germany and Switzerland AHA recommends that your IT department block emails from these two countries unless you do business with them
SPAM Email from HEN or HIIN Finance mdash PLEASE IGNORE
If you receive an email asking you to pay your invoice via a link please ignore and permanently delete Do not click on the link in the email The email may come from different email addresses but is titled as HENHIIN Finance or HRET HIIN similar to what is pictured below
41
Hospital Leadership and Quality Assessment Tool
The tool measures board members C-suite executives and managementsupervisors on how well they are implementing evidence-based practices shown to support a culture of safety and high performance in clinical quality measures
No front-line staff survey component
Survey content
FAQ
42
HLQAT Survey
MHA is providing this complimentary opportunity for all HIIN hospitals to access and utilize this survey
Two options
Phase I mdash Completed
Phase II mdash April through August 2018
ndash Available to all HIIN hospitals mdash previous participation not
required
ndash Phase I hospitals may participate in phase II if desired
ndash Intent to participate materials will be sent to HIIN contacts soon
43
Qualaris Audit Tool Projects
Hand Hygiene
Culture of Safety Rounding
Sepsis
ReadmissionsCare Transitions
44
Qualaris mdash New Tools
Qualaris has new tools to assist users with coordinating successful improvement projects
Tracking project outcomes alongside process measures
Real-time dashboards inclusive of both outcomes and process measures
Documenting PDSAs
Click here to view the Qualaris improvement projects and outcomes demo
These tools require a short setup webinar session with Qualaris
Readmission Immersion Project participants should contact supportqualariscom
Use the Qualaris virtual chat support for next steps
45
LEAN Six Sigma Green Belt Project
Project launching mdashMarch 13 2018 through November 30 2018
Hospitals committed mdash20
Topic-focused
Patient throughput
ICU harm reduction
Errors in medication reconciliation
46
Capital Region Medical Center
Carroll County Memorial Hospital
Cass Regional Medical Center
Cox Medical Center
Fitzgibbon Hospital
Golden Valley Memorial Healthcare
Hannibal Regional Hospital
Lafayette Regional Health Center
Lake Regional Health System
Liberty Hospital
North Kansas City Hospital
Ozark Medical Center
Perry County Memorial Hospital
Saint Lukes Health System
Saint Lukes Hospital Kansas City
Scotland County Hospital
Southeast Missouri Hospital
St Marys Medical Center
Ste Genevieve County Memorial Hospital
Western Missouri Medical Center
NHSN Reporting Facilities
The January 23rd release of the NHSN 881 application will introduce an updated NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled in NHSN prior to December 2 2017 Facilities that enrolled in NHSN on or after December 2 2017 have already accessed this new Consent and will not need to accept it again if they have already done so
Primary Contacts or Facility Administrators should agree to this updated Consent form for each component by April 14th 2018 or risk losing access to NHSN
An alert will appear on all NHSN component home pages and primary contacts and facility administrators will receive an email notification
Additional information including Frequently Asked Questions and the updated NHSN purposes are available on CDCs NHSN website If you have any questions please send an email to NHSNcdcgov with the subject line ldquoNHSN Reconsentrdquo
47
NHSN Reporting Facilities
The NHSN team has published informational guidance on our website to assist users with completion of the updated NHSN Agreement to Participate and Consent A 5-minute video informs users of the new Consent purposes and the simple process for accepting the Consent electronically Furthermore a step-by-step guidance document provides detailed instructions and screen shots for what Facility Administrators and Primary Contacts can expect to see when they begin the re-consent process in the NHSN application A link to the video and the guidance document can both be found in the FAQs About NHSNrsquos Agreement to Participate and Consent
48
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
MHA ldquoZero Heroesrdquo Club
MHA congratulates the following HIIN-participating hospitals with the most zero harm measures reported These organizations have either achieved andor sustained a zero rate of harm and are in the top 10 percent of HIIN-participating hospitals Congratulations to the ldquoZero Herosrdquo for the month of September
Carroll County Memorial Hospital
Ellett Memorial Hospital
Harrison County Community Hospital
Iron County Medical Center
Osage Beach Center for Cognitive Disorders
Pike County Memorial Hospital
Southeast Health Center of Ripley County
Sullivan County Memorial Hospital
40
AHArsquos IT department investigated the emails and discovered they were generated by groups from Germany and Switzerland AHA recommends that your IT department block emails from these two countries unless you do business with them
SPAM Email from HEN or HIIN Finance mdash PLEASE IGNORE
If you receive an email asking you to pay your invoice via a link please ignore and permanently delete Do not click on the link in the email The email may come from different email addresses but is titled as HENHIIN Finance or HRET HIIN similar to what is pictured below
41
Hospital Leadership and Quality Assessment Tool
The tool measures board members C-suite executives and managementsupervisors on how well they are implementing evidence-based practices shown to support a culture of safety and high performance in clinical quality measures
No front-line staff survey component
Survey content
FAQ
42
HLQAT Survey
MHA is providing this complimentary opportunity for all HIIN hospitals to access and utilize this survey
Two options
Phase I mdash Completed
Phase II mdash April through August 2018
ndash Available to all HIIN hospitals mdash previous participation not
required
ndash Phase I hospitals may participate in phase II if desired
ndash Intent to participate materials will be sent to HIIN contacts soon
43
Qualaris Audit Tool Projects
Hand Hygiene
Culture of Safety Rounding
Sepsis
ReadmissionsCare Transitions
44
Qualaris mdash New Tools
Qualaris has new tools to assist users with coordinating successful improvement projects
Tracking project outcomes alongside process measures
Real-time dashboards inclusive of both outcomes and process measures
Documenting PDSAs
Click here to view the Qualaris improvement projects and outcomes demo
These tools require a short setup webinar session with Qualaris
Readmission Immersion Project participants should contact supportqualariscom
Use the Qualaris virtual chat support for next steps
45
LEAN Six Sigma Green Belt Project
Project launching mdashMarch 13 2018 through November 30 2018
Hospitals committed mdash20
Topic-focused
Patient throughput
ICU harm reduction
Errors in medication reconciliation
46
Capital Region Medical Center
Carroll County Memorial Hospital
Cass Regional Medical Center
Cox Medical Center
Fitzgibbon Hospital
Golden Valley Memorial Healthcare
Hannibal Regional Hospital
Lafayette Regional Health Center
Lake Regional Health System
Liberty Hospital
North Kansas City Hospital
Ozark Medical Center
Perry County Memorial Hospital
Saint Lukes Health System
Saint Lukes Hospital Kansas City
Scotland County Hospital
Southeast Missouri Hospital
St Marys Medical Center
Ste Genevieve County Memorial Hospital
Western Missouri Medical Center
NHSN Reporting Facilities
The January 23rd release of the NHSN 881 application will introduce an updated NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled in NHSN prior to December 2 2017 Facilities that enrolled in NHSN on or after December 2 2017 have already accessed this new Consent and will not need to accept it again if they have already done so
Primary Contacts or Facility Administrators should agree to this updated Consent form for each component by April 14th 2018 or risk losing access to NHSN
An alert will appear on all NHSN component home pages and primary contacts and facility administrators will receive an email notification
Additional information including Frequently Asked Questions and the updated NHSN purposes are available on CDCs NHSN website If you have any questions please send an email to NHSNcdcgov with the subject line ldquoNHSN Reconsentrdquo
47
NHSN Reporting Facilities
The NHSN team has published informational guidance on our website to assist users with completion of the updated NHSN Agreement to Participate and Consent A 5-minute video informs users of the new Consent purposes and the simple process for accepting the Consent electronically Furthermore a step-by-step guidance document provides detailed instructions and screen shots for what Facility Administrators and Primary Contacts can expect to see when they begin the re-consent process in the NHSN application A link to the video and the guidance document can both be found in the FAQs About NHSNrsquos Agreement to Participate and Consent
48
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
AHArsquos IT department investigated the emails and discovered they were generated by groups from Germany and Switzerland AHA recommends that your IT department block emails from these two countries unless you do business with them
SPAM Email from HEN or HIIN Finance mdash PLEASE IGNORE
If you receive an email asking you to pay your invoice via a link please ignore and permanently delete Do not click on the link in the email The email may come from different email addresses but is titled as HENHIIN Finance or HRET HIIN similar to what is pictured below
41
Hospital Leadership and Quality Assessment Tool
The tool measures board members C-suite executives and managementsupervisors on how well they are implementing evidence-based practices shown to support a culture of safety and high performance in clinical quality measures
No front-line staff survey component
Survey content
FAQ
42
HLQAT Survey
MHA is providing this complimentary opportunity for all HIIN hospitals to access and utilize this survey
Two options
Phase I mdash Completed
Phase II mdash April through August 2018
ndash Available to all HIIN hospitals mdash previous participation not
required
ndash Phase I hospitals may participate in phase II if desired
ndash Intent to participate materials will be sent to HIIN contacts soon
43
Qualaris Audit Tool Projects
Hand Hygiene
Culture of Safety Rounding
Sepsis
ReadmissionsCare Transitions
44
Qualaris mdash New Tools
Qualaris has new tools to assist users with coordinating successful improvement projects
Tracking project outcomes alongside process measures
Real-time dashboards inclusive of both outcomes and process measures
Documenting PDSAs
Click here to view the Qualaris improvement projects and outcomes demo
These tools require a short setup webinar session with Qualaris
Readmission Immersion Project participants should contact supportqualariscom
Use the Qualaris virtual chat support for next steps
45
LEAN Six Sigma Green Belt Project
Project launching mdashMarch 13 2018 through November 30 2018
Hospitals committed mdash20
Topic-focused
Patient throughput
ICU harm reduction
Errors in medication reconciliation
46
Capital Region Medical Center
Carroll County Memorial Hospital
Cass Regional Medical Center
Cox Medical Center
Fitzgibbon Hospital
Golden Valley Memorial Healthcare
Hannibal Regional Hospital
Lafayette Regional Health Center
Lake Regional Health System
Liberty Hospital
North Kansas City Hospital
Ozark Medical Center
Perry County Memorial Hospital
Saint Lukes Health System
Saint Lukes Hospital Kansas City
Scotland County Hospital
Southeast Missouri Hospital
St Marys Medical Center
Ste Genevieve County Memorial Hospital
Western Missouri Medical Center
NHSN Reporting Facilities
The January 23rd release of the NHSN 881 application will introduce an updated NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled in NHSN prior to December 2 2017 Facilities that enrolled in NHSN on or after December 2 2017 have already accessed this new Consent and will not need to accept it again if they have already done so
Primary Contacts or Facility Administrators should agree to this updated Consent form for each component by April 14th 2018 or risk losing access to NHSN
An alert will appear on all NHSN component home pages and primary contacts and facility administrators will receive an email notification
Additional information including Frequently Asked Questions and the updated NHSN purposes are available on CDCs NHSN website If you have any questions please send an email to NHSNcdcgov with the subject line ldquoNHSN Reconsentrdquo
47
NHSN Reporting Facilities
The NHSN team has published informational guidance on our website to assist users with completion of the updated NHSN Agreement to Participate and Consent A 5-minute video informs users of the new Consent purposes and the simple process for accepting the Consent electronically Furthermore a step-by-step guidance document provides detailed instructions and screen shots for what Facility Administrators and Primary Contacts can expect to see when they begin the re-consent process in the NHSN application A link to the video and the guidance document can both be found in the FAQs About NHSNrsquos Agreement to Participate and Consent
48
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
Hospital Leadership and Quality Assessment Tool
The tool measures board members C-suite executives and managementsupervisors on how well they are implementing evidence-based practices shown to support a culture of safety and high performance in clinical quality measures
No front-line staff survey component
Survey content
FAQ
42
HLQAT Survey
MHA is providing this complimentary opportunity for all HIIN hospitals to access and utilize this survey
Two options
Phase I mdash Completed
Phase II mdash April through August 2018
ndash Available to all HIIN hospitals mdash previous participation not
required
ndash Phase I hospitals may participate in phase II if desired
ndash Intent to participate materials will be sent to HIIN contacts soon
43
Qualaris Audit Tool Projects
Hand Hygiene
Culture of Safety Rounding
Sepsis
ReadmissionsCare Transitions
44
Qualaris mdash New Tools
Qualaris has new tools to assist users with coordinating successful improvement projects
Tracking project outcomes alongside process measures
Real-time dashboards inclusive of both outcomes and process measures
Documenting PDSAs
Click here to view the Qualaris improvement projects and outcomes demo
These tools require a short setup webinar session with Qualaris
Readmission Immersion Project participants should contact supportqualariscom
Use the Qualaris virtual chat support for next steps
45
LEAN Six Sigma Green Belt Project
Project launching mdashMarch 13 2018 through November 30 2018
Hospitals committed mdash20
Topic-focused
Patient throughput
ICU harm reduction
Errors in medication reconciliation
46
Capital Region Medical Center
Carroll County Memorial Hospital
Cass Regional Medical Center
Cox Medical Center
Fitzgibbon Hospital
Golden Valley Memorial Healthcare
Hannibal Regional Hospital
Lafayette Regional Health Center
Lake Regional Health System
Liberty Hospital
North Kansas City Hospital
Ozark Medical Center
Perry County Memorial Hospital
Saint Lukes Health System
Saint Lukes Hospital Kansas City
Scotland County Hospital
Southeast Missouri Hospital
St Marys Medical Center
Ste Genevieve County Memorial Hospital
Western Missouri Medical Center
NHSN Reporting Facilities
The January 23rd release of the NHSN 881 application will introduce an updated NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled in NHSN prior to December 2 2017 Facilities that enrolled in NHSN on or after December 2 2017 have already accessed this new Consent and will not need to accept it again if they have already done so
Primary Contacts or Facility Administrators should agree to this updated Consent form for each component by April 14th 2018 or risk losing access to NHSN
An alert will appear on all NHSN component home pages and primary contacts and facility administrators will receive an email notification
Additional information including Frequently Asked Questions and the updated NHSN purposes are available on CDCs NHSN website If you have any questions please send an email to NHSNcdcgov with the subject line ldquoNHSN Reconsentrdquo
47
NHSN Reporting Facilities
The NHSN team has published informational guidance on our website to assist users with completion of the updated NHSN Agreement to Participate and Consent A 5-minute video informs users of the new Consent purposes and the simple process for accepting the Consent electronically Furthermore a step-by-step guidance document provides detailed instructions and screen shots for what Facility Administrators and Primary Contacts can expect to see when they begin the re-consent process in the NHSN application A link to the video and the guidance document can both be found in the FAQs About NHSNrsquos Agreement to Participate and Consent
48
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
HLQAT Survey
MHA is providing this complimentary opportunity for all HIIN hospitals to access and utilize this survey
Two options
Phase I mdash Completed
Phase II mdash April through August 2018
ndash Available to all HIIN hospitals mdash previous participation not
required
ndash Phase I hospitals may participate in phase II if desired
ndash Intent to participate materials will be sent to HIIN contacts soon
43
Qualaris Audit Tool Projects
Hand Hygiene
Culture of Safety Rounding
Sepsis
ReadmissionsCare Transitions
44
Qualaris mdash New Tools
Qualaris has new tools to assist users with coordinating successful improvement projects
Tracking project outcomes alongside process measures
Real-time dashboards inclusive of both outcomes and process measures
Documenting PDSAs
Click here to view the Qualaris improvement projects and outcomes demo
These tools require a short setup webinar session with Qualaris
Readmission Immersion Project participants should contact supportqualariscom
Use the Qualaris virtual chat support for next steps
45
LEAN Six Sigma Green Belt Project
Project launching mdashMarch 13 2018 through November 30 2018
Hospitals committed mdash20
Topic-focused
Patient throughput
ICU harm reduction
Errors in medication reconciliation
46
Capital Region Medical Center
Carroll County Memorial Hospital
Cass Regional Medical Center
Cox Medical Center
Fitzgibbon Hospital
Golden Valley Memorial Healthcare
Hannibal Regional Hospital
Lafayette Regional Health Center
Lake Regional Health System
Liberty Hospital
North Kansas City Hospital
Ozark Medical Center
Perry County Memorial Hospital
Saint Lukes Health System
Saint Lukes Hospital Kansas City
Scotland County Hospital
Southeast Missouri Hospital
St Marys Medical Center
Ste Genevieve County Memorial Hospital
Western Missouri Medical Center
NHSN Reporting Facilities
The January 23rd release of the NHSN 881 application will introduce an updated NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled in NHSN prior to December 2 2017 Facilities that enrolled in NHSN on or after December 2 2017 have already accessed this new Consent and will not need to accept it again if they have already done so
Primary Contacts or Facility Administrators should agree to this updated Consent form for each component by April 14th 2018 or risk losing access to NHSN
An alert will appear on all NHSN component home pages and primary contacts and facility administrators will receive an email notification
Additional information including Frequently Asked Questions and the updated NHSN purposes are available on CDCs NHSN website If you have any questions please send an email to NHSNcdcgov with the subject line ldquoNHSN Reconsentrdquo
47
NHSN Reporting Facilities
The NHSN team has published informational guidance on our website to assist users with completion of the updated NHSN Agreement to Participate and Consent A 5-minute video informs users of the new Consent purposes and the simple process for accepting the Consent electronically Furthermore a step-by-step guidance document provides detailed instructions and screen shots for what Facility Administrators and Primary Contacts can expect to see when they begin the re-consent process in the NHSN application A link to the video and the guidance document can both be found in the FAQs About NHSNrsquos Agreement to Participate and Consent
48
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
Qualaris Audit Tool Projects
Hand Hygiene
Culture of Safety Rounding
Sepsis
ReadmissionsCare Transitions
44
Qualaris mdash New Tools
Qualaris has new tools to assist users with coordinating successful improvement projects
Tracking project outcomes alongside process measures
Real-time dashboards inclusive of both outcomes and process measures
Documenting PDSAs
Click here to view the Qualaris improvement projects and outcomes demo
These tools require a short setup webinar session with Qualaris
Readmission Immersion Project participants should contact supportqualariscom
Use the Qualaris virtual chat support for next steps
45
LEAN Six Sigma Green Belt Project
Project launching mdashMarch 13 2018 through November 30 2018
Hospitals committed mdash20
Topic-focused
Patient throughput
ICU harm reduction
Errors in medication reconciliation
46
Capital Region Medical Center
Carroll County Memorial Hospital
Cass Regional Medical Center
Cox Medical Center
Fitzgibbon Hospital
Golden Valley Memorial Healthcare
Hannibal Regional Hospital
Lafayette Regional Health Center
Lake Regional Health System
Liberty Hospital
North Kansas City Hospital
Ozark Medical Center
Perry County Memorial Hospital
Saint Lukes Health System
Saint Lukes Hospital Kansas City
Scotland County Hospital
Southeast Missouri Hospital
St Marys Medical Center
Ste Genevieve County Memorial Hospital
Western Missouri Medical Center
NHSN Reporting Facilities
The January 23rd release of the NHSN 881 application will introduce an updated NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled in NHSN prior to December 2 2017 Facilities that enrolled in NHSN on or after December 2 2017 have already accessed this new Consent and will not need to accept it again if they have already done so
Primary Contacts or Facility Administrators should agree to this updated Consent form for each component by April 14th 2018 or risk losing access to NHSN
An alert will appear on all NHSN component home pages and primary contacts and facility administrators will receive an email notification
Additional information including Frequently Asked Questions and the updated NHSN purposes are available on CDCs NHSN website If you have any questions please send an email to NHSNcdcgov with the subject line ldquoNHSN Reconsentrdquo
47
NHSN Reporting Facilities
The NHSN team has published informational guidance on our website to assist users with completion of the updated NHSN Agreement to Participate and Consent A 5-minute video informs users of the new Consent purposes and the simple process for accepting the Consent electronically Furthermore a step-by-step guidance document provides detailed instructions and screen shots for what Facility Administrators and Primary Contacts can expect to see when they begin the re-consent process in the NHSN application A link to the video and the guidance document can both be found in the FAQs About NHSNrsquos Agreement to Participate and Consent
48
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
Qualaris mdash New Tools
Qualaris has new tools to assist users with coordinating successful improvement projects
Tracking project outcomes alongside process measures
Real-time dashboards inclusive of both outcomes and process measures
Documenting PDSAs
Click here to view the Qualaris improvement projects and outcomes demo
These tools require a short setup webinar session with Qualaris
Readmission Immersion Project participants should contact supportqualariscom
Use the Qualaris virtual chat support for next steps
45
LEAN Six Sigma Green Belt Project
Project launching mdashMarch 13 2018 through November 30 2018
Hospitals committed mdash20
Topic-focused
Patient throughput
ICU harm reduction
Errors in medication reconciliation
46
Capital Region Medical Center
Carroll County Memorial Hospital
Cass Regional Medical Center
Cox Medical Center
Fitzgibbon Hospital
Golden Valley Memorial Healthcare
Hannibal Regional Hospital
Lafayette Regional Health Center
Lake Regional Health System
Liberty Hospital
North Kansas City Hospital
Ozark Medical Center
Perry County Memorial Hospital
Saint Lukes Health System
Saint Lukes Hospital Kansas City
Scotland County Hospital
Southeast Missouri Hospital
St Marys Medical Center
Ste Genevieve County Memorial Hospital
Western Missouri Medical Center
NHSN Reporting Facilities
The January 23rd release of the NHSN 881 application will introduce an updated NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled in NHSN prior to December 2 2017 Facilities that enrolled in NHSN on or after December 2 2017 have already accessed this new Consent and will not need to accept it again if they have already done so
Primary Contacts or Facility Administrators should agree to this updated Consent form for each component by April 14th 2018 or risk losing access to NHSN
An alert will appear on all NHSN component home pages and primary contacts and facility administrators will receive an email notification
Additional information including Frequently Asked Questions and the updated NHSN purposes are available on CDCs NHSN website If you have any questions please send an email to NHSNcdcgov with the subject line ldquoNHSN Reconsentrdquo
47
NHSN Reporting Facilities
The NHSN team has published informational guidance on our website to assist users with completion of the updated NHSN Agreement to Participate and Consent A 5-minute video informs users of the new Consent purposes and the simple process for accepting the Consent electronically Furthermore a step-by-step guidance document provides detailed instructions and screen shots for what Facility Administrators and Primary Contacts can expect to see when they begin the re-consent process in the NHSN application A link to the video and the guidance document can both be found in the FAQs About NHSNrsquos Agreement to Participate and Consent
48
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
LEAN Six Sigma Green Belt Project
Project launching mdashMarch 13 2018 through November 30 2018
Hospitals committed mdash20
Topic-focused
Patient throughput
ICU harm reduction
Errors in medication reconciliation
46
Capital Region Medical Center
Carroll County Memorial Hospital
Cass Regional Medical Center
Cox Medical Center
Fitzgibbon Hospital
Golden Valley Memorial Healthcare
Hannibal Regional Hospital
Lafayette Regional Health Center
Lake Regional Health System
Liberty Hospital
North Kansas City Hospital
Ozark Medical Center
Perry County Memorial Hospital
Saint Lukes Health System
Saint Lukes Hospital Kansas City
Scotland County Hospital
Southeast Missouri Hospital
St Marys Medical Center
Ste Genevieve County Memorial Hospital
Western Missouri Medical Center
NHSN Reporting Facilities
The January 23rd release of the NHSN 881 application will introduce an updated NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled in NHSN prior to December 2 2017 Facilities that enrolled in NHSN on or after December 2 2017 have already accessed this new Consent and will not need to accept it again if they have already done so
Primary Contacts or Facility Administrators should agree to this updated Consent form for each component by April 14th 2018 or risk losing access to NHSN
An alert will appear on all NHSN component home pages and primary contacts and facility administrators will receive an email notification
Additional information including Frequently Asked Questions and the updated NHSN purposes are available on CDCs NHSN website If you have any questions please send an email to NHSNcdcgov with the subject line ldquoNHSN Reconsentrdquo
47
NHSN Reporting Facilities
The NHSN team has published informational guidance on our website to assist users with completion of the updated NHSN Agreement to Participate and Consent A 5-minute video informs users of the new Consent purposes and the simple process for accepting the Consent electronically Furthermore a step-by-step guidance document provides detailed instructions and screen shots for what Facility Administrators and Primary Contacts can expect to see when they begin the re-consent process in the NHSN application A link to the video and the guidance document can both be found in the FAQs About NHSNrsquos Agreement to Participate and Consent
48
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
NHSN Reporting Facilities
The January 23rd release of the NHSN 881 application will introduce an updated NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled in NHSN prior to December 2 2017 Facilities that enrolled in NHSN on or after December 2 2017 have already accessed this new Consent and will not need to accept it again if they have already done so
Primary Contacts or Facility Administrators should agree to this updated Consent form for each component by April 14th 2018 or risk losing access to NHSN
An alert will appear on all NHSN component home pages and primary contacts and facility administrators will receive an email notification
Additional information including Frequently Asked Questions and the updated NHSN purposes are available on CDCs NHSN website If you have any questions please send an email to NHSNcdcgov with the subject line ldquoNHSN Reconsentrdquo
47
NHSN Reporting Facilities
The NHSN team has published informational guidance on our website to assist users with completion of the updated NHSN Agreement to Participate and Consent A 5-minute video informs users of the new Consent purposes and the simple process for accepting the Consent electronically Furthermore a step-by-step guidance document provides detailed instructions and screen shots for what Facility Administrators and Primary Contacts can expect to see when they begin the re-consent process in the NHSN application A link to the video and the guidance document can both be found in the FAQs About NHSNrsquos Agreement to Participate and Consent
48
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
NHSN Reporting Facilities
The NHSN team has published informational guidance on our website to assist users with completion of the updated NHSN Agreement to Participate and Consent A 5-minute video informs users of the new Consent purposes and the simple process for accepting the Consent electronically Furthermore a step-by-step guidance document provides detailed instructions and screen shots for what Facility Administrators and Primary Contacts can expect to see when they begin the re-consent process in the NHSN application A link to the video and the guidance document can both be found in the FAQs About NHSNrsquos Agreement to Participate and Consent
48
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
HRETHIIN Virtual Events
49
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
Partnership for Patients NCD Pacing Event | Reducing Harm at Critical Access HospitalsMarch 29 2018 | 1200 - 100 pm CT | Register here
50
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
HRET HIIN Readmissions | Reducing Sepsis Readmissions Fishbowl Series 1April 10 2018 | 1100 am - 1200 pm CT | Register here
Nationally sepsis accounts for both a high number of readmissions and high readmission rate Yet many people are unaware of the signs and symptoms of sepsis and the big problems facing individuals who are discharged after having sepsis According to the Sepsis Alliance Awareness Survey - 2017 Sepsis is the 1 cause for readmissions to the hospital costing more than 2 billion a year and 50 of the readmissions occur due to unresolved or recurrent infections
During this five month series you an listen to the five hospital participants who are in the fishbowl as they test new strategies to reduce sepsis readmissions in their organizations You will hear new ideas that you can adapt for your own sepsis readmissions improvement efforts
51
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 6
11 am Wednesday March 28
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 6
1230 pm Wednesday March 28
Register here
52
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Office Hours 4
11 am Wednesday April 4
Register here
HRET HIIN QI Fellowship |Culture of Safety
11 am Friday April 6
This is a highly recommended event for all QI fellows
In this webinar fellows will learn to describe what we mean by a culture of safety discuss the evolution of culture and explain how the science of improvement can be used to drive change in an organization Register here
53
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
QI Fellowship Virtual Events
HRET HIIN QI Fellowship | Foundations for Change Call 7
11 am Wednesday April 11
Register here
HRET HIIN QI Fellowship | Accelerating Improvement Call 7
1230 pm Wednesday April 11
Register here
54
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
Upcoming Virtual Events
55
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
HIIN Huddles
2 pm Tuesday May 22
Script Up Milestone 7
Register here
2 pm Tuesday July 24
Milestone 8 HIIN Quality Convening Recap HRO
Register here
2 pm Tuesday September 25
Project CloseRecap Whatrsquos Coming
Register here56
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
Upcoming Events
57
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
HIIN Quality Convening
Beyond reducing harm and readmissions health care leaders and providers must understand how to instill and support a culture that promotes safety high quality care and engagement of patients and families Providing safe environments to both patients and staff is essential to achieving optimal outcomes
This interactive conference will provide health care workers leaders and consumers with strategies and examples to succeed in improving care and sustaining improvements
58
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
HIIN Quality Convening
Attendees will have the opportunity to collaborate with colleagues and think critically about the care provision at their organization
ldquoKeeping the Behavioral Health Patient Saferdquo will be a keynote discussion at this convening
There will be operational and technical initiatives discussed to provide tools for building an organizational culture of safety including strategies to support and sustain that culture
59
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
HIIN Quality Convening 2018
Wednesday June 6 and Thursday June 7 2018
Courtyard by Marriott in Columbia Missouri
Complimentary registration for Missouri hospitals Register on or before Wednesday May 23
60
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
Missouri HIIN Conference 2018
ldquoKeeping the Behavioral Health Patient Saferdquo mdash Joel A
Dvoskin PhD ABPP
Chair Nevada Behavioral Health and Wellness Council
Forensic and Clinical Psychologist
61
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
Hotel Information
Missouri HIIN Conference
Block of rooms reserved
Calling to book HIN
Online booking
ndash King bed HINA
ndash Two queen beds HINB
Courtyard Marriott
573-443-8000
62
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
Dates
Session 1 mdash Sept 8 2017
Session 2 mdash Oct 6 2017
Session 3 mdash Nov 10 2017
Session 4 mdash Jan 12 2018
Session 5 mdash Feb 9 2018
Session 6 mdash Mar 9 2018
Session 7 mdash Apr 13 2018
Session 8 mdash May 11 2018
Upcoming Events
15th Annual Health Care Leadership Series 2017-2018
The Health Care Leadership Series consists of eight one-day training sessions that will be held monthly on Fridays September through May There will be no session in December
Sessions will be held at the Courtyard by Marriott in Columbia Missouri
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment 63
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
Upcoming Events
Orientation for New Infection Prevention Professionals Wednesday May 2 and Thursday May 3
Courtyard by Marriott Columbia Mo
Register on or before April 18
ndash MHA Member $375
This conference will prepare new infection prevention health care professionals to be facilitators and resources for surveillance prevention and control of infections It will aid professionals new to the responsibilities of infection prevention in managing the everyday duties of infection surveillance analysis of disease data problem identification and resolution This program will benefit acute long-term residential ambulatory care public health rehabilitation home health and mental health disciplines It will enhance existing programs through a presentation of current guidelines and evidence-based practices applicable to infection control programs product selection and evaluation This conference allows participants to engage in hands-on case study group review activities and applications of user-friendly tools to enhance their infection prevention programs and goals
64
Events are not paid through HIIN We encourage HIIN-participating hospitals to use HIIN stipends to assist in payment
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
Upcoming Events Save the Date
CPHQ Review Course
Monday July 16 and Tuesday July 17
Tan-Tar-A Resort Osage Beach MO
ndash Cost $449
ndash Space is limited to 75 registrants
ndash Individuals from HIIN hospitals will receive reimbursement for the course if
bull CPHQ exam is taken within four weeks of the review course
bull Present the certificate from the completed review course
bull Results from completed exam show a ldquoPassrdquo status
bull All documents submitted no later than August 21 201865
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
Educational Resources Provided by MHA Health Institute
For additional webinarseminar opportunities click here66
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
Resources
67
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
SME Monthly Spotlights
Adverse Drug Events mdash Opioid Safety in the Hospital
Falls Prevention
Hospital Acquired Infections
Patient and Family Engagement
Pressure Ulcer
VTE Prevention and Management
68
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
Eliminating Harm Improving Patient Care A Trustee Guide
These resources were designed to illustrate the important role that trustees play in the journey to improve patient care They serve as a tool for all trustees to use as they work towards the goals of improving quality within their organizations and improving the health of their patients and communities they serve Four new video modules and a discussion guide have been developed as well as a self-assessmenttool for boards
Topics include
The Importance of Ongoing Board Education
Boards Can Influence Quality Through a Focus on Population Health
Clinician Engagement is Crucial to Improving Quality
The Importance of Patient and Family Engagement in Improving Quality
69
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
To Care is Human ndash Collectively Confronting the Clinician-Burnout Crisis
From the New England Journal of Medicine
Physician burnout remains a critical threat to physician well-being and patient safety In this commentary leaders of the National Academy of Medicine the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout teach about its dangers and foster meaningful solutions
70
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
Opioid Crisis ndash At a Glance
This new infographic from the National Institute for Health Care Management (NIHCM) Foundation shows data on opioid-related emergency room visits and inpatient stays data on opioid overdose deaths data on states increasingly responding to the opioid crisis and more
71
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
NEW STOP to START Improve Falls
Nine myths about falls are busted
Six practices we must STOP doing are listed with replacement interventions and strategies to START doing
Links are provided to the articles with evidence to support the STOPS and STARTS
Links to tools and resources to support evidence based patient centered fall injury prevention practices and strategies including
Patient Centered Care Injury Prevention
Safe Mobilization
Delirium Assessment
Medication Review
Patient Family Engagement
Interdisciplinary Resources
72
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
HRET Harm Topics
Information regarding harm
Change package
Checklists
Fact sheets
Additional resources
Webinar recordings
Podcasts
73
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages
These change packages are a summary of themes from the successful practices of high performing health organizations across the country
They have been developed through clinical practice sharing organization site visits and subject matter expert contributions
These change packages include a menu of strategies change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources
74
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
ListServ
Get access to other hospitals subject matter experts and other resources to avoid reinventing the wheel
Listserv sign-up open through the duration of the HIIN Sign up today
75
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
Monthly Quality Newsletter
Click here for past issues76
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
MHA Trajectories
ldquoBroadening the Culture of Safety Addressing Workplace Violence rdquo
77Click here for March Trajectories
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
Questions
78
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
Missouri HIIN Team
bullJessica Stultz RN BSN MHA CPHQ
bullDirector of Clinical Quality
bull573893-3700 ext 1391
bulljstultzmhanetcom
Jessica Stultz
bullAmanda Keilholz CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1405
bullakeilholzmhanetcom
Amanda Keilholz
bullToi Wilde RN BSN MBA CPHQ
bullHIIN Program Manager
bull573893-3700 ext 1406
bulltwildemhanetcom
Toi Wilde
bullMary Shackelford RN BSN
bullImprovement Advisor
bullmshackelfordmhanetcom
Mary Shackelford
79
