Statit pimd Client Panel Guy March, Product Lead, Midas+ Statit
Statit pimd/ppr Statit Software Started ~25 years ago Currently serving 650 hospitals Guy March Working with Statit QC products for over 20 years
Presenters: Cathy Brice - CaroMont Health HAC early warning Aimee Miter Kaiser San Diego Monitoring Serious Safety Events Linda Justice - Spartanburg Regional Infection Prevention
Early Detection/Intervention with Harm Events
CaroMont Regional Medical Center Not-for-profit health system headquartered in Gastonia, NC Employs 3,900 healthcare professional Medical Staff Membership of more than 450 Comprises 5 entities: CaroMont Regional Medical Center CaroMont Medical Group Gaston Hospice Courtland Terrace CaroMont Specialty Surgery
CaroMont Regional Medical Center 435-bed acute care hospital State-of-the-Art Cancer Center Birthplace with Neonatal Intensive Care Unit Level III Trauma Center A few of our achievements TJC Center of Excellence Stroke Heart Failure Joint Care Magnet Recognition
It all started with HAC Beginning with discharges occurring on or after October 1, 2008, Medicare does not assign an inpatient hospital discharge to the higher paying MSDRG if an HAC (e.g., surgical site infection) was not present upon admission. Pursuant to the Health Reform Law, beginning in FY 2015, hospitals will face an additional 1% reduction in Medicare inpatient payments if they fall into the top 25% of national risk-adjusted HAC rates for all hospitals in the previous year.
And along came VBP Enhanced payments for quality, Value-Based Purchasing (Sections 3001, 10335 of PPACA): First, in FY 2013, hospitals will receive increased base rate per discharge payments for meeting certain clinical quality measures for specified conditions, including acute myocardial infarction, heart failure, certain surgical procedures, healthcare-associated infections and pneumonia. In FY 2014, HHS must ensure that the payment formula includes efficiency measures, such as Medicare spending per beneficiary. Funding for these payments will be generated through reduced inpatient PPS payments to hospitals in the following amounts for the following fiscal years: 1% for 2013, 1.25% for 2014, 1.5% for 2015, 1.75% for 2016, and 2% for 2017 and thereafter.
Where we started Indicators built identifying qualifying encounters Spreadsheet produced 25 days out from the end of the month Multi-disciplinary team formed Harm Committee- Nursing, Presenter Quality Name of Life Committee Presenter,LAB, Name Presenter Title Presenter Title Medical Records, Admitting, Pharmacy, Surgery etc. Reviewed patients with harm events Determined if issue was people or process Remedies and recommendations were activated
CMS/HAC CMS HAC Report with Quest Facility: All Facilities Indicator Jan 2013 Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2013 Total Foreign Body Left During Procedure X 0 0 0 0 0 0 0 0 0 0 0 0 0 Air Embolism X 0 0 0 0 0 0 0 0 0 0 0 0 0 Blood Incompatibility X 0 0 0 0 0 0 0 0 0 0 0 0 0 Pressure Ulcers, Stage III and IV X 0 0 0 0 0 0 0 0 0 0 0 0 0 Hospital Acquired Injuries X 1 0 1 0 0 0 0 0 0 0 0 0 2 Catheter Associated UTI X 0 2 0 0 0 0 0 2 1 0 0 1 6 Infection from Central Venous Catheter (Incl code 999.33) X 0 0 0 0 0 0 0 0 1 0 1 0 2 Poor Glycemic Control X 0 0 0 0 0 0 0 0 0 0 0 0 0 Mediastinitis after CABG X 0 0 0 0 0 0 0 0 0 0 0 0 0 Surgical Site Infections, Orthopedic X 0 0 0 0 0 0 0 0 0 0 0 0 0 Surgical Site Infections, Bariatric X 0 0 0 0 0 0 0 0 0 0 0 0 0 Surgical Site Infections, CIED X 0 0 1 0 0 0 0 0 0 0 0 0 1 DVT/PE, Orthopedic X 0 0 0 0 0 0 0 0 1 0 1 0 2 Iatrogenic Pneumothorax with Venous Cath X 0 0 0 1 0 1 0 0 0 0 0 0 2
Encounter-level Data Tab
Where were are now Statit Indicators for each Harm Event Eliminate Rebilling Set Triggers for any Activity Reduce Opportunity for recurrence Email Alerts Expedite Resolution Initiate Research
Email Alert Every AM with event
Email Alert Received from Statit
Click Path to Details
Option to identify encounter-level detail
Encounter-level information in two clicks
Setting Notification Options
Questions?
Kaiser San Diego Statit Journey
Kaiser San Diego
Kaiser SD Statit Overview Statit pimd Quality Scorecards Patient Safety Scorecards Leadership Scorecards Compliance Scorecards Infection Control Statit PPR Physician OPPE Profiles Nursing Department Profiles Unit Based Team Profiles
Profiles for each physician and allied health specialty providing chiefs and credentialing committee tools for documenting OPPE.
Typical physician specialty profile
Nursing Unit Profile view by all or single unit
Unit Based Team Profiles
Statit Scorecards Quality Peer Review Oversight Patient Safety Days Since Last Infection Control Leadership Core Measure Compliance Project Scorecards ie: Falls
Patient Safety Scorecard
Infection Control Scorecard Annotations
Lessons Learned OPPE - Start with a clear vision standardized indicators and scope specific Clean provider table Scorecard ownership and accountability Vision for the Future Increasingly robust OPPE indicators Promote PI features functionality/expert engagement Thank you! Statit Support, Dan, Guy, Jon, Bill, Steve & Cole
Kaiser San Diego Contact Information:
Statit pimd & Infection Prevention What are your options for scorecards?
Consider your data source when designing your scorecard Do you want to use standardized rates with national benchmarks? Does your numerator and denominator come form the same source? Do you utilize the distributed Midas toolkits?
NHSN Analysis Export From within CDC-NHSN run the analysis CMS defined output Save the data as excel in a file accessible to your Statit server Define your data source Define desire indicators Presenter Name Presenter Title
Each Excel sheet will be a data source
ICP Section of QAPI Scorecard
Attend Hands-on Training
Use Data Streams for rates with Numerator and Denominators from separate Data sources
Output from Data Stream-based Indicator
Utilize the Midas+ Toolkits - Develop indicators and profile for data
Final Tips Be Creative Use the data you have and choose the best way to present Consider your audience Be Transparent Return on Investment - Statit pimd can use many data sources