2014 silver award recipient american hospital association (aha)/health research & educational...
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2014 Silver Award Recipient
American Hospital Association (AHA)/Health Research & Educational Trust (HRET)
Hospital Engagement Network (HEN) 2.0 Hospital Kick-off
Tuesday, September 29 &Thursday, October 1, 2015
1:00-3:00 PM CT
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2014 Silver Award Recipient
WELCOME AND INTRODUCTIONS
Maulik Joshi, Associate Executive Vice President, AHA Clinical Leadership and Health Improvement; President, HRETJessica (Blake) McNab, Director, HRET1:00-1:10 PM
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2014 Silver Award Recipient
First Things First
• Congratulations!• We are excited to have the HEN 2.0 contract• We are looking forward to working with you,
your state hospital associations, your patients and their families
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2014 Silver Award Recipient
Agenda for Today1:00-1:10 PM Welcome from the AHA/HRET Team Open and provide housekeeping information.
Welcome and overview of the project along with initial thoughts on keys to success in this project.
Jessica McNabDirector, Clinical QualityMaulik JoshiPresident
1:10-1:15 PM Welcome from CMS Welcome hospitals to the HEN 2.0 project. Shelly Coyle
Nurse Consultant, DHHS, CMS
1:15-1:20 PM Keys to HEN 2.0 Success – Additional Areas of Focus Review additional key strategies for success. Ken Anderson
Chief Operating Officer
1:20-1:30 PM Project Scope and Goals Provide background on the HEN project and the goals for 2015-2016 and benefits to participation. Charisse Coulombe
Vice President, Clinical Quality
1:30-1:50 PM Education Opportunities Outline national education offerings at the national level, including meetings, the fellowship and topic-specific webinars. Jessica McNab
1:50-2:05 PM Data Expectations and Support Introduce data expectations and the support that will be provided by HRET to meet the project aims, including the
Comprehensive Data System.Mariana LesherDirector, Data
2:05-2:15 PM Technical Assistance and Targeted Offerings Summarize opportunities for hospital participants to receive targeted support, including office hours, technical assistance
and affinity groups.Sarah Bender &Marissa KumabeProgram Managers
2:15-2:30 PM What’s Next for You Provide details on how to engage, including the Needs Assessment and HEN 2.0 website. Natalie Erb &
Angela MichalekProgram Managers
2:30-2:40 PM Action Items Discuss any next steps and how we will support you in accomplishing them. Charisse Coulombe
Vice President, Clinical Quality
2:40-3:00 PM Q & A and Closing Questions for the HRET team All
2014 Silver Award Recipient
Bold Aims
12-month SPRINT to reduce all-cause preventable inpatient harm by 40% and readmissions by 20%
1. Be in action to support your patients and their families by committing to this project
2. Work to reduce harm across the board 3. Learn together by sharing your hospital stories –
successes and opportunities4. Data is the foundation of all improvement at the unit
level, hospital level, state and national level
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2014 Silver Award Recipient
WELCOME FROM CMS
Shelly Coyle, Nurse Consultant and AHA/HRET’s COR, DHHS, CMS 1:10-1:15 PM
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KEYS TO HEN 2.0 SUCCESS
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Ken Anderson, Chief Operating Officer, HRET1:15-1:20 PM
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PROJECT SCOPE AND GOALS
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Charisse Coulombe, Vice President, HRET1:20-1:30 PM
2014 Silver Award Recipient
HENs: What are they?
Hospital Engagement Networks 2.0
• Improvement collaborative• Best-practice incubator• Community of peers • Learning cohort
• Quality improvement (QI)• Clinical content
• Similar to the original HEN project from 2011-2014 regarding focus and bold aims
• Different regarding standardized measures and accelerated timeframes
2014 Silver Award Recipient
PfP HENs for HEN 2.01. AHA/HRET2. Ascension Health3. Carolinas HealthCare System4. Dignity Health5. Healthcare Assoc. of NY State6. Health Research Education Trust of NJ7. Hosp. & Healthsystem Assoc. of PA8. IA Healthcare Collaborative9. LifePoint Health
10. MI Health and Hosp. Assoc. Health Found.11. MN Hosp. Assoc.12. OH Children’s Hosp. Solutions for Pt. Safety13. OH Hospital Assoc.14. Premier Inc.15. TN Hospital Assoc.16. VHA-UHC Alliance NewCo Inc.17. WA State Hosp. Assoc.
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2014 Silver Award Recipient
The AHA/HRET HEN Structure
Patients & Families
Hospital Team
State Hospital Association (SHA) Team
AHA/HRET HEN Team
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Core Topics – Aim is 40% reduction
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1. Adverse Drug Events (ADE)2. Catheter-associated Urinary Tract Infections (CAUTI)3. Central line-associated Blood Stream Infections (CLABSI)4. Early Elective Deliveries and Obstetrical (OB) Harm5. Injuries from Falls and Immobility6. Pressure Ulcers (PrU)7. Surgical Site Infections (SSI)8. Venous Thromboembolisms (VTE)9. Ventilator Associated Events (VAE)10. Readmissions (20% reduction)
2014 Silver Award Recipient
All Other Forms of Harm
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1. Airway Safety2. Clostridium difficile (C. diff)3. Culture of Safety4. Failure to Rescue5. Iatrogenic Delirium6. Radiation Exposure7. Sepsis
2014 Silver Award Recipient
Special Topics of Focus
• Patient and Family Engagement (PFE) • Health Care Disparities (HCD)
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AHA/HRET HEN Team
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Our Partners
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1.State hospital associations (SHAs): Hospital support2.Cynosure Health: Clinical education3.Institute for Healthcare (IHI): Quality improvement education
4.University of Michigan (U of M): CAUTI education5.Operations and Logistics 6.Communications, Graphic Design and 508 Compliance7.Continuing education
2014 Silver Award Recipient
The Timeline
12/1/2014 - HEN 2.0 Pre-Solic
itation Release
d
12/8/2014 - HEN 1.0 Ends
2/11/2015 - HEN 2.0 RFP Released
3/27/2015 – AHA/HRET HEN 2.0 Proposal S
ubmitted
7/21/2015 – SHA Convening & Questi
ons from CMS Rece
ived
7/31/2015 – AHA/HRET HEN 2.0 Revise
d Proposal Submitted
9/24/2015 – CMS Execu
tes Contra
ct with
AHA/HRET
HEN 2.0
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9/23/2016 – Project End
2014 Silver Award Recipient
What We Know• Project Period
– 12 months
• Aim– Reduce all-cause preventable harm by 40%; readmissions
by 20%
• Required Measures for Core Topics– 17 outcome measures
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2014 Silver Award Recipient
AHA/HRET HEN 2.0 Overall Plan
• We have not had an opportunity to discuss these details with CMS– These plans are subject to change pending CMS
feedback– We wanted to share the preliminary details to help you
understand the support we plan to provide• As soon as we can, we will provide you and your
SHA with additional details for project components, such as finalized adverse drug event (ADE) measures, etc.
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Stay tuned!
2014 Silver Award Recipient
Our Commitment
• To leverage HEN 1.0 successes and learnings• To communicate early and often via our main
communication tool - the HRET HEN 2.0 website• To support you and your state hospital
association in the best way possible to achieve the project goals
• To move as quickly as we can to achieve the 40 / 20 percent reduction in harm!
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2014 Silver Award Recipient
EDUCATION OPPORTUNITIES
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Jessica (Blake) McNab, Director, HRET1:30-1:50 PM
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Visit Our New Website!
2014 Silver Award Recipient
Where to Find Your SHA Details
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Overview of Our HEN 2.0 Plan
Biweekly 90-minute Topic-specific Webinars
Two Annual National Scientific In-person Meetings
Monthly Data Webinars
Bimonthly Rural/CAH Affinity Group Webinars
Foundational HEN Action Leader Fellowship
Experienced HEN Action Leader Fellowship
SHA-led M
eetingsSite Visits
Hospital-level Improvement
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2014 Silver Award Recipient
Topic and Data Webinars
• Topic webinars– We have designed shorter, mid-day webinars to help you
incorporate education into your (busy!) schedules and to keep your focus in the unit
• Approximately twice a week • No more than 90 minutes long
– Topics will be prioritized based on our direction from CMS and project data, including a needs assessment (which will be explained in more detail)
• Data webinars – Will cover how you can use project data to inform quality
improvement, including baseline statistics– Approximately once a month
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Fellowship• Foundational HEN Action Leader Fellowship: Track offered for new
HEN participants or those new to quality improvement • Experienced HEN Action Leader Fellowship: Track offered to
experienced HEN participants or those who have been focused on quality improvement and patient safety for more than five years
• Details for each include:– Monthly webinars building on learnings throughout the project– Action Learning Projects (ALPs) that will highlight individual or hospital
progress toward HEN project goals– Opportunity to meet and network with other Fellows at in-person
national scientific meetings– Sharing of ALPs on website upon completion– Certificate of completion upon project submission
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Registration details will be communicated soon!
2014 Silver Award Recipient
Hospital Onboarding Checklist
2014 Silver Award Recipient
Education This Month
September 29, 1-3 PM CT – Hospital Kickoff WebinarOctober 1, 1-3 PM CT – Hospital Kickoff Webinar (repeat)October 6, 11-12:30 PM CT – Hospital Data Intro WebinarOctober 8, 11-12:30 PM CT – Hospital Data Intro Webinar
(repeat)October 13 & 15, 11-12:30 PM CT – Tentative
Readmissions and CAUTI WebinarsOctober 20 – Tentative Fellowship Kickoff
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√√
2014 Silver Award Recipient
Chat Us!
What are you most excited about in HEN 2.0?
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DATA DETAILS
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Mariana Lesher, Director, HRET1:50-2:05 PM
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Measurement Philosophy
• Simple, straightforward, explainable• Capitalize on existing data where possible• Use standardized measures • Be responsive to unique needs
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HEN 2.0 Data Components
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Component Frequency / date dueNeeds assessment Once, upon enrollment, by Nov 16Baseline outcome and process measures data
Once, upon enrollment (timeframe TBD)
Monitoring outcome and process measures data
Monthly, by last day of month following close of month (except readmissions)Start date TBD
Operational items Monthly, by last day of month following close of month
2014 Silver Award Recipient
Needs Assessment – by Nov 16
• Basic hospital information• HEN topic prioritization and measurement practices• Quality improvement efforts• Patient and family engagement practices• Leadership and governance activities• Disparities data collection efforts• Cultural competency practices• HEN contacts
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Program Evaluation MeasuresFocus Area CMS Required Evaluation Measure(s)
CAUTI
NHSN1 Reporting Facilities: CAUTI Standardized Infection Ratio (SIR) (NQF 0138) o Intensive Care Unit (ICU) Units, excluding Neonatal Intensive Care Units (NICU)o ICU + Other units
• All Facilities: CAUTI Rates (CAUTIs /1,000 catheter days, CAUTIs / 10,000 pt days) o ICU Units, excluding NICUo ICU + Other inpatient units
All Facilities: Urinary-catheter utilization ratio (catheter days / 10,000 pt days)
CLABSI
NHSN1 Reporting Facilities: CLABSI SIR - (NQF 0139)o ICU Units, including NICUo ICU + Other units
All Facilities: CLABSI Rates (CLABSIs / 1,000 central line days, CLABSIs / 10,000 pt days)o ICU Units, including NICUo ICU + Other inpatient units
All Facilities: Central-line utilization ratio (central line days / patient days)
[1] Hospitals reporting CAUTI, CLABSI, SSI and VAE data may confer rights to their data to the AHA/HRET or another group to meet the measurement requirements for this topic. All other hospitals are expected to follow the NHSN definitions of the measures and will submit numerators and denominators. Rates will be calculated based on numerators and denominators.
2014 Silver Award Recipient
Program Evaluation Measures, cont’dFocus Area CMS Required Evaluation Measure(s)
Falls Falls with injury (NQF 0202)
Obstetrical (OB) adverse events
Early elective deliveries (EED) (PC-01, NQF 0469) Vaginal deliveries with instrument (Agency for Healthcare Research &
Quality [AHRQ] PSI 18) Vaginal deliveries without instrument (AHRQ PSI 19)
Pressure ulcers (PrU)
PrU rate, Stages 3+ (AHRQ PSI-03) PrU prevalence (hospital-acquired), Stage 2+ (NQF 0201)
Surgical site infections (SSI)
NHSN1 Reporting Facilities: SSI SIR (NQF 0753)o Colon surgerieso Abdominal hysterectomyo Total hip replacementso Total knee replacements
• All Facilities: SSI Rates (# infections / # surgeries)o Colon surgerieso Abdominal hysterectomyo Total hip replacementso Total knee replacements
[1] Hospitals reporting CAUTI, CLABSI, SSI and VAE data may confer rights to their data to the AHA/HRET or another group to meet the measurement requirements for this topic. All other hospitals are expected to follow the NHSN definitions of the measures and will submit numerators and denominators. Rates will be calculated based on numerators and denominators.
2014 Silver Award Recipient
Program Evaluation Measures, cont’d
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VAE Ventilator-Associated Condition (VAC) Infection-Related Ventilator-Associated Complication (IVAC)
VTE Post-Operative pulmonary embolism (PE) or deep vein thrombosis (DVT) rate (AHRQ PSI-12)
Adverse drug events (ADE)
ADEs per 1,000 patient days ADEs due to opioids Excessive anticoagulation with warfarin Hypoglycemia in patients receiving insulin
Readmissions All cause 30-day readmissions
Other outcome and process measures may be added, as well as other topic measures.
2014 Silver Award Recipient
Setting Up for Success
Education Encyclopedia of Measures
Data Intro Webinars
Monthly Data
Webinars
Technical Support
[email protected] Office Hours
CDS Platform Enhancements
Data validation Reports
Other Resources
Improvement Calculator
Harm Across the Board
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2014 Silver Award Recipient
Comprehensive Data System (CDS)
• Secure, web-based data collection and reporting system for HRET projects
• Will support all hospital-level data submission and reporting for HEN 2.0
• Expanded and enhanced features since HEN 1.0
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2014 Silver Award Recipient
Immediate Next Steps for Data
1. Review resources from your SHA / website– Encyclopedia of measures– Needs assessment– CDS Quick Start Guide
2. Join a Data Intro Webinar next week– Tues Oct. 6 and Thurs Oct. 8, 11-12:30 PM CT
3. Return your signed commitment letter for access to CDS
4. Start collecting and submitting data!
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TECHNICAL ASSISTANCE AND TARGETED OFFERINGS
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Sarah Bender, Program Manager, HRETMarissa Kumabe, Program Manager, HRET2:05-2:15 PM
2014 Silver Award Recipient
Technical AssistanceDon’t worry! We’re here to help!
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AHA/HRET offers two types of technical assistance:• Shared inboxes• Office hours
2014 Silver Award Recipient
AHA/HRET Shared Inboxes
• HEN Inbox ([email protected]): – Available for any technical or national project support
needs. Emails to be reviewed and responded to within two business days.
• HRET Data Support Inbox ([email protected]): – Available for data-specific questions about the project,
including CDS, which will be responded to within two business days.
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2014 Silver Award Recipient
AHA/HRET Office Hours
• Data: – Twice monthly opportunities to speak with the
HRET data team for troubleshooting around data in CDS, reports and any measure specification questions.
• Quality improvement: – Twice monthly opportunities to speak to quality
improvement advisors for troubleshooting around your facility projects and how to overcome barriers.
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2014 Silver Award Recipient
Targeted Offerings
• Rural and Critical Access Hospitals (CAH)– Affinity group webinars
• Offerings every other month to address issues that are unique to rural and CAH hospitals
– Customized materials:• Rural/CAH Data Collection Tool• Rural/CAH LISTSERV®• Others, as needed or identified…
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2014 Silver Award Recipient
Your SHAs
And obviously, your SHA contacts will be wonderful resources to you as you go through
the project!
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2014 Silver Award Recipient
WHAT’S NEXT FOR YOU
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Angela Michalek, Program Manager, HRETNatalie Erb, Program Manager, HRET2:05-2:15 PM
2014 Silver Award Recipient
LISTSERV® Update• The HEN 1.0 LISTSERVs® will sunset this week, and the HEN 2.0
LISTSERVs® will launch• Hospital participants will need to sign up through the website
(no one will be automatically subscribed)• Committed hospitals will be subscribed
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2014 Silver Award Recipient
LISTSERVs®
• Subscriber-based email group• Each email group covers a different topic or
group of topics• Ideal for:
– Peer-shared learnings– Asking questions about barriers– Sharing data-collection opportunities– Clarifications about measures or
inclusion/exclusion criteria
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2014 Silver Award Recipient
Site Visits
• Your SHA will contact you to set up a mutually agreeable date and time for them to visit and review the project, data and your organization’s goals
• During site visits:– Complete a site-visit action plan with the SHA
• After site visits:– Your SHA will submit the site-visit action plan into our CDS, where you
will be able to view it and track progress
• We will be using this information to help us report on the quality and quantity of site visits, a crucial part of our HEN 2.0 strategy
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2014 Silver Award Recipient
Commitment Letter
Will be filled in for you
Summary of you and your
team's commitment to
achieve the HEN 2.0 project
goals
Summary of CMS required measures for
quick reference
2014 Silver Award Recipient
Commitment Letter
Summary of CMS required measures for
quick reference
2014 Silver Award Recipient
Commitment Letter
Summary of optional topics
HRET commitments to you and your team
SHA will have their contact information included so you can
have their information as a quick
reference
You and your team to complete and sign and return to your
listed SHA
2014 Silver Award Recipient
Commitment Letter Details
• Contact your SHA for a copy of your state’s commitment letter
• Due date is at the discretion of your SHA• Commits to: 1) working on all applicable topics; 2)
submitting data on all applicable topics (and required measures); and 3) collaboration and sharing
• Summarizes CMS requirements• Collects CEO and HEN lead signature and contact
information
2014 Silver Award Recipient
Next StepsAssemble your team.
Recruit an executive champion, physician champions, a project lead, data support and multidisciplinary support from across your organization.
Access resources on www.hret-hen.org. Search for resources by topic or type of resource Access SHA information
Register for events. Watch the Upcoming Events page for webinars that are relevant to you.
Celebrate! You are committing to an extraordinary national initiative to improve care.
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ACTION ITEMS
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Charisse Coulombe, Vice President, HRET2:30-2:40 PM
2014 Silver Award Recipient
Re-cap of Action Items Assemble your team and celebrate!
Join a hospital kick-off webinar, data kick-off webinar and other
upcoming events as they are scheduled
Get on HRET-HEN website
Review project and data resources
Submit your Letter of Commitment to your SHA
Complete your Needs Assessment in CDS
Schedule your first SHA site visit
Submit baseline and monitoring data into CDS
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What and Who
• General ?s: [email protected] • Data ?s: [email protected]• Clinical ?s: Topic LISTSERVs®• And, of course – Your SHA
2014 Silver Award Recipient
Questions
Questions?
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