MHA Keystone Center. MICAH QN Meeting May 18, 2018

Transcription

1 MHA Keystone Center MICAH QN Meeting May 18, 2018

2 Agenda ADEs due to Opioids measure Sepsis measures a) Post-Operative Sepsis (PSI-13) b) Sepsis Mortality Rate Falls with Injury measure Person & Family Engagement HRM HIIN Reliability Measure Upcoming Educational Opportunities

3 Data submission reminder June 15 Data entry for the Blue Cross PG5 P4P program year (April March 2018) is June 15 Final Scores for the program will come out via in late June. This includes Manual Entry measures via KDS ADE (All 3 - Anticoagulation, Hypoglycemia & ADEs due to Opioids) Falls with Injury Person & Family Engagement NHSN (Infection Measures) C Diff MRSA CAUTI CLABSI VAE SSI (through Q4 2017) Surgical Site Infection (SSI) data will include submission for April 2017-December If you enter infection measures via NHSN please be mindful that the deadline for the Blue Cross program data submission is June 15. This does not follow the usual NHSN deadline but is needed for the Blue Cross P4P program. If someone else at your facility enters these measures please notify them of this deadline for the BC P4P PG5 program. Reminder, If your hospital has already been clarified as ineligible to collect a specific measure(s) then you do NOT need to enter those measures, that has not changed.

4 ADEs due to Opioids (ADE-4)

5 FAQ ADE due to Opioids

6 Community Site Resources

7 Gap Analysis

8 ADE due to Opioids PG5 has LOWER rates than PG1-4 and other hospitals in the HIIN for ADE related to Opioids

9 ADE due to Opioids

10 ADE due to Opioids Performance Data included: 2016 Q Q1 Benchmark Period: 2016 Q Q3 ADE - Opioids HIIN CAH Benchmark = MI IL WI GLPP Total CAH Number of CAH

11 Sepsis What is Sepsis? Sepsis is the body s overwhelming and life-threating response to infection which can lead to tissue damage, organ failure, and death. Faces of Sepsis (sepsis.org)

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14 Post-Op Sepsis (PSI-13)

15 PSI 13 Post-op Sepsis AHRQ Quality Indicators (AHRQ QI ) ICD-10-CM/PCS Specification Version 6.0 Patient Safety Indicator 13 (PSI 13) Postoperative Sepsis Rate July Provider-Level Indicator Type of Score: Rate DESCRIPTION Postoperative sepsis cases (secondary diagnosis) per 1,000 elective surgical discharges for patients ages 18 years and older. Excludes cases with a principal diagnosis of sepsis, cases with a secondary diagnosis of sepsis present on admission, cases with a principal diagnosis of infection, cases with a secondary diagnosis of infection present on admission (only if they also have a secondary diagnosis of sepsis), obstetric discharges, and cases with missing values as listed in denominator section.

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19 GLPP Webinar: Recognize and Manage Sepsis in the Post-Acute Setting - December 19, e9baf08&tab=librarydocuments

20 Sepsis Resources Community Site

21 Post-Op Sepsis Rate INCREASING for CAH

22 Post-Op Sepsis Rate INCREASING for CAH

23 Sepsis Mortality

24 Sepsis Mortality

25 Sepsis Mortality Michigan CAH Only Data included: 2015 Q Q3 Average = 17.8

26 Falls with Injury

27 NQF 0202

28 Injury levels (NQF 0202)

29 Falls with Injury PG5 has higher rates than PG1-4 and other hospitals in the HIIN for Falls with Injury

30 Falls with Injury

31 Falls Rate

32 Falls with Injury Performance Data included: 2016 Q Q1 Benchmark Period: 2016 Q Q3 Falls HIIN CAH Benchmark = MI IL WI GLPP Total CAH Number of CAH

33 CAH Benchmarks MI IL WI GLPP Total CAH Number of CAH

34 CAH Benchmarks MI IL WI GLPP Total CAH Number of CAH Q Q3 Benchmark Period, All HIIN CAH Falls = ADE - Opioid-related =

35 PFE Status - MICAH Members PFE Status - MICAH Members PFE 1 - Planning Checklist Fully Implemented or NA PFE 2 - Shift Change Huddles Fully Implemented PFE 3 - Responsible Party Fully Implemented PFE 4 - PFAC/ Patient advisor on QI Team Fully Implemented PFE 5 - Governing Board Fully Implemented

36 PFE Status - MICAH Members 40 PFE Status - MICAH Members No scheduled admissions Fully Implemented Partially Implemented Not Implemented 5 0 PFE 1 - Planning Checklist PFE 2 - Shift Change Huddles PFE 3 - Responsible Party PFE 4 - PFAC/ Patient advisor on QI Team PFE 5 - Governing Board

37 PFE Status - MICAH Members 40 PFE Status - MICAH Members No scheduled admissions Fully Implemented Partially Implemented Not Implemented 5 0 PFE 1 - Planning Checklist PFE 2 - Shift Change Huddles PFE 3 - Responsible Party PFE 4 - PFAC/ Patient advisor on QI Team PFE 5 - Governing Board

38 PFE Reminders/Updates MHA Data Team will no longer copy comments month to month Make a comment when you update your status - check for previous comments We are seeing month after month comments of In discussion or Goal in near future carried on without meaningful, recent input Good example of comments: Year Month PFE 1 - Planning Checklist PFE 1 - Comment Not Implemented We are working with Marketing to have the checklist placed in a new Patient admission booklet Not Implemented Not Implemented Marketing will have the checklist placed in a new Patient admission booklet in August Fully Implemented

39 PFE Reminders/Updates Only one month can be edited at a time for PFE If you need records updated going back several months, notify MHA staff No Scheduled Admissions is an option in the dropdown for PFE-1; please do not submit Not Implemented if this is the case Option was added June 2017; adjustments made by MHA staff on previous entries

40 HIIN Reliability Measure (HRM) Instead of focusing on individual topic areas, the HRM was designed to gauge overall trends in adverse events for each hospital HRM meant to address internal questions like: o Do we tend to have more adverse events in summer or winter? (Quarterly seasonality) o Are we seeing more infections of all types due to hand hygiene issues? (CAUTI, C.diff, etc.) o When we implemented a new Speak Up program, did overall events decline due to harms being avoided? Ratio involving patient days not appropriate for small-volume facilities due to varying data sources & surveillance windows

41 Storyboard Improvement Activity

42 Sample Final Storyboard

43 PSO Update June 12: Noon 3 pm PSO Safe Table focused on OB adverse events Grand Valley University LV Eberhard Ctr, Grand Rapids June 20: 8 am 4:30 pm PSO Root Cause Analysis & Action Training Bronson Methodist Hospital, Kalamazoo

44 CAH Falls Webinar June 15, 1pm GLPP HIIN Essential Steps to Protect Patients from Injurious Falls in Acute & Critical Access Hospitals with Patricia Quigley, PHD June pm (ET)

45 Save the Date 2018 MHA Patient Safety & Quality Symposium September 19, 2018 Ann Arbor Marriott Ypsilanti at Eagle Crest 2018 MHA Keystone Fall Workshop October 23, 2018 JW Marriott, Grand Rapids

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