hospital improvement innovation network (hiin)web.mhanet.com/sqi/hiin/january2017hiinhuddle.pdf ·...

HOSPITAL IMPROVEMENT INNOVATION NETWORK (HIIN)

Jessica Rowden, MHA, BSN, R.N., CPHQ

Director of Clinical Quality

HIIN Hierarchy

Centers for Medicare & Medicaid Services

15 other prime HIIN contractors

American Hospital Association/Health Research and Educational Trust

31 other state hospital associations

1,600 hospitals

Missouri Hospital Association

86 hospitals*

Survey Data

Needs Assessment

One-time

Survey Monkey – for submission

Patient and Family Engagement

Quarterly

HIDI Quality Collections

Needs Assessment

Hospital Demographics

Comparative Groups

EHR Vendor

Topic Level Involvement

Patient and Family Engagement Questions

Additional Missouri Questions

Excel Support

Statistics Support

Data Support

QI Support

Patient and Family Engagement

Quarterly

HIDI Quality Collections

Abstracted Measures

HIINformational Data

Data Submission Assistance (encourage monthly)

Abstracted– Templates

– Quality Collections

Claims

NHSN

Reports

Baseline

Project

– Monthly

– Quarterly

Mission:20 percent harm reduction12 percent readmission reduction

Measures for ALL Hospitals

Measures for SPECIFIC Hospitals

Data Submission: Abstracted Measures

For abstracted measures, you have the choice to either submit data on the data submission excel templates and email to your Improvement Advisor on a monthly basis

OR You can submit your data directly into Quality Collections on a

monthly basis

Data Submission: Abstracted Measures

Data Submission Templates (monthly)

Data Submission: Abstracted Measures

HIDI Quality Collections

https://www.hidianalyticadvantage.com/Analytics/Home.aspx

Data Due Dates – HIIN Project Yr 1

Task

Deadline For Hospital to

Submit Data Data Included in DeadlineBaseline 17-Jan BaselineJanuary Monthly Monitoring Data 23-Jan Oct-DecFebruary Monthly Monitoring Data 20-Feb Oct-JanMid-Year Report 8-Mar Oct-JanMarch Monthly Monitoring Data 23-Mar Oct-FebApril Monthly Monitoring Data 20-Apr Oct-MarchMilestone 4 8-May Hard dealine for ALL data Oct-FebMay Monthly Monitoring Data 22-May Oct-AprilJune Monthly Monitoring Data 22-Jun Oct-MayJuly Monthly Monitoring Data 21-Jul Oct-JuneAugust Monthly Monitoring Data 23-Aug Oct-JulyTarget Report 6-Sep Oct-JulySeptember Monthly Monitoring Data 19-Sep Oct-AugMilestone 5 14-Sep Hard deadline for ALL data Oct-MayOctober Monthly Monitoring Data 23-Oct Oct-Sept

Data Submission: NHSN/Claims

NHSN

Confer rights

Ensure data is entered monthly

Ensure data is entered for HIIN measures

Claims

Hospital billing department sends data monthly/quarterly to HIDI

HIDI processes data quarterly to supply claims measure data for HIIN project

Confer Your NHSN Data to HIDI

Why?

To provide you the most robust data portfolio

To better assist you with more improvement opportunities

See the Instructional Guide

Improvement Calculator Harms prevented

Costs saved

Lives saved (NEW!)

Easier to use

Based on pivot tables (not macros)

Updated cost estimates

Reports

Baseline Data

Monthly Performance

– Current

– Aggregate/Project

Missing data

Topics meeting goal

Opportunities

Quarterly CEO dashboard

HIIN lead preview period of dashboard

Education

Data Education

Formal Quality and Process Improvement

Fellowships

IHI Open School

Webinars

Coaching Calls

Site Visits

HIINcredible Fellowship Opportunity

Additional benefits of participation including

Developing or deepening your skills in quality improvement

The opportunity to share with and learn from colleagues seeking to make similar improvements

Coaching from IHI Improvement Advisors

Access to the IHI Open School virtual courses

Efforts to create improvement leaders through the fellowship program are associated with improvement in outcomes

Two Fellowship Tracts

Foundations for Change Fellowship Accelerating Improvement Fellowship

Tailored to those who are new to quality improvement

Tailored to those with previous QI experience who are looking to deepen their knowledge and skills

Fellows will learn how to : deploy tools such as aim

statements, driver diagrams, and

run charts to initiate and nurture

improvement

galvanize others to participate in

your improvement efforts

develop and sustain momentum

mitigate common improvement

pitfalls

Fellows will learn how to : assess whether your QI efforts are set up

for success

utilize data to identify, drive, and sustain

performance improvement

ensure process reliability and

sustainability

plan for spread and scale

mitigate common improvement pitfalls

Patient and Family Engagement

FellowshipGoal is to get at least one fellow signed up per hospital

Quality Improvement

H11N 8Y TH3 NUM83R5

HIIN Stats

86 Participating Hospitals

73 ACC

13 Rehab/Psych/LTAC

CAH/Rural numbers

–25 CAH

–43 Rural

Needs Assessments: 100% of ACC

Site Visits: 15/73 = 21%

About 75% of the remaining are scheduled

Fellowship Numbers

Quality Improvement

Basic/Foundational = 16

Advanced/Accelerated Improvement = 11

Patient and Family Engagement = 6

Please sign up by end of February

Administration will receive a memo within the next 10 business days

ListServ

Missouri HIIN Participants = 46

Please sign up and DELEGATE!

To prevent inbox clutter, create a “rule”

If you need help with this, ask your IA

Get access to other hospitals, subject matter experts, and other resources so you aren’t stuck reinventing the wheel

Delegation Tips

Think outside the box

Get nursing/direct patient care staff more involved in the “behind-the-scenes” work

Include nursing management and front-line staff in webinars, QI projects, listservs, fellowships

Build quality improvement education into the clinical ladder

Identify nurses/other staff furthering their education and are in need of projects for school

Encourage nurses/other staff to further their education and give them a project for school – contact us for HPOG grants!

Immersion Projects

In Progress

Antibiotic Stewardship Program

Workplace Violence

Coming CY 2017

Sepsis

Readmissions

Brainstorming – late 2017 or 2018

Lean/SS

Leadership

HAI

Up Campaign

Two foundational questions:

1. Is my patient awake enough to get up?

2. Have I protected my patient against infections?

Our National HIIN Team

National Project Team

Kimberly King, HRET – State Liaison

Julia Heitzer, HRET – Data Liaison

Betsy Lee, Cynosure Health – SME Liaison

New HRET Offerings/Resources

Strategic Innovation Engine (SIE) - Spreading Innovative Practices in Health Care Quality: CMS' Quality Improvement Organization program recently established the SIE to help advance quality and health care innovations. If your hospital has established a practice that has improved care in one of CMS' six quality strategy goals, we encourage you to email info@sie.qioprogram.org or visit http://sie.qioprogram.org/ for more information.

New HRET Resources

New HRET Offerings/Resources

Safety Network to Accelerate Performance (SNAP): Enhanced Recovery After Colorectal Surgery: The first SNAP topic is enhanced recovery after surgery with a focus on colorectal surgery. This topic aligns well with HIIN SSI reduction efforts and links to the UP Campaign, specifically with the Get UP initiative to promote early progressive mobility. The SNAP page and application are now on the HRET HIIN website. Hospitals that are interested in participating in this SNAP should register for the informational call on February 2 at 2:00 p.m. CT. The registration link is available on the 'SNAP' and 'Upcoming Events' pages of the website.

New HRET Offerings/Resources

Fishbowl Series: HRET is hosting a fishbowl series for ADE and readmissions that will begin in April 2017 and run for five consecutive months. We are recruiting for three participating hospitals to be 'in the fishbowl' receiving real time coaching while other hospitals listen in each month. These hospitals should be able to commit to attend the virtual events over the five month period and be willing to share their struggles and successes in ADE reduction efforts

Be HIINvolved!

Share your stories!

Be HIIN the know!

Participate in webinars

– Delegate!

– Get your team involved!

Help us make HIIN a household name!

Ask your IA your hospital questions!

Let us visit and celebrate or work through barriers with you!

Help us HIINcrease safety and quality across the board

Upcoming HRET Webinars

NCD Pacing Event | Front-Line Staff Culture Change

January 26, 2017 | 12:00 p.m. - 1:00 p.m. CT | Register here.

HRET HIIN | CLABSI

January 26, 2017 | 11:00 a.m. - 11:50 a.m. CT | Register here.

HRET HIIN | ERAS SNAP Informational Call

February 2, 2017 | 2:00 p.m. - 3:00 p.m. CT | Register here.

HRET HIIN | VTE Virtual Event

February 7, 2017 | 11:00 a.m. - 12:00 p.m. CT | Register here.

HRET HIIN | PFE Fellowship

February 8, 2017 | 11:00 a.m. - 12:00 p.m. CT | Register here.

HRET HIIN | ADE | Adjuncts and Alternatives to Opioids for Pain: It's All About Love

February 14, 2017 | 12:00p.m. - 12:50p.m. CT | Register here

2017 Aim for Excellence ConferenceJoin the Missouri Hospital Association at the inaugural Aim for Excellence Conference, designed to both highlight the achievements of Missouri hospitals and inform on trending topics leading to the Triple Aim – better health, better care, lower costs.

The winners of the inaugural 2016 Aim for Excellence awards will present their work and the conference will also include a special session and open discussion on Missouri initiatives to combat opioid misuse. Lear

Thursday, April 6 and Friday, April 7, 2017Columbia Courtyard by Marriott

David Nash, M.D., MBAPeter Almenoff, M.D., FCCP

Kerry Johnson

Register Now

Registration deadline: Thursday, March 30

MHA SQI Webinars

What’s Up Wednesdays

First Wednesday of the month at noon

Register

HIIN Huddles

Fourth Tuesday of the month at 2:00 p.m.

Register

Missouri HIIN Team

•Jessica Rowden, RN, BSN, MHA, CPHQ

•Director of Clinical Quality

•573/893-3700, ext. 1391

•jrowden@mhanet.com

Jessica Rowden

•Amanda Keilholz

•HIIN Program Manager

•573/893-3700, ext. 1405

•akeilholz@mhanet.com

Amanda Keilholz

•Toi Wilde, RN, BSN, MBA

•HIIN Program Manager

•573/893-3700, ext. 1406

•twilde@mhanet.com

Toi Wilde

•Mary Shackelford, RN, BSN

•Improvement Advisor

•mshackelford@mhanet.com

Mary Shackelford