The Hospital Engagement Networks: Moving the Dial on

Quality in New Mexico

CMS Partnership for Patients Goals

3,700 participating hospitals:• Making Care Safer – Preventable hospital-

acquired conditions decrease by 40 percent compared to 2010

• Improving Care Transitions – Hospital readmissions reduce by 20 percent compared to 2010

Making Care Safer, Improving Care Transitions

1. Adverse Drug Events2. Catheter-Associated

Urinary Tract Infections3. Central Line-Associated

Blood Stream Infections4. Injuries from Falls and

Immobility5. Obstetrical Adverse Events

‒ Early Elective Deliveries‒ Post partum hemorrhage‒ Pre-eclampsia

6. Pressure Ulcers7. Surgical Site Infections8. Venous Thromboembolism9. Ventilator-Associated

Pneumonia/Events10. Readmissions

– 30 day all cause

HACs

26 P4P Hospital Engagement NetworksIncludes the Health Research & Educational Trust (HRET), an affiliate of the American Hospital Association (AHA) 1,419 hospitals, 31 states

NM HEN: 23 hospitals

InterMountain HealthcareNM: 6 hospitals*Presbyterian Health System

Lifepoint Hospitals, Inc.NM: 2 hospitals * Memorial Medical Center* Los Alamos Medical Center

31 NM hospitals

NM HEN: Protecting NM Patients from Harm*

• 1675 harms prevented • $11,397,335 saved in health care costs

due to HACs• Early elective deliveries reduced by 77%• Readmissions reduced by 8%• Post operative DVT/PE reduced by 44%• Surgical site infections reduced by 63%• Pressure ulcers (stage III or greater)

reduced by 71%• OB: 3rd and 4th degree lacerations

reduced by 26%• Falls reduced by 37%

*Improvement as of 9/15/2014

NM HEN Successes• 78% of the NM HEN hospitals submit data for ALL topics• 96 different process and outcome measures are being used

by the NM HEN hospitals• 13,957 entries have been made to the Comprehensive Data

System• 29 Improvement Leader Fellows in NM hospitals• Birthed the statewide Perinatal Collaborative• 14 hospital staff have presented at state and national

meetings/webinars

Your NMHA

HEN Team

2012-2014

Española HospitalIntermountain Healthcare HEN

Lincoln County Medical CenterIntermountain Healthcare HEN

Plains Regional Medical CenterIntermountain Healthcare HEN

Presbyterian Central Delivery SystemIntermountain Healthcare HEN

• Beth Shields• Judy Sanchez

Socorro General HospitalIntermountain Healthcare HEN

• Veronica Pound

Los Alamos Medical CenterLifePoint Hospitals, Inc. HEN

• Tracie Stratton

Memorial Medical CenterLifePoint Hospitals, Inc. HEN

• Ann DeBooy

NM HEN Hospitals Recognition

Advanced Care Hospital of Southern New Mexicoand

Rehabilitation Hospital of Southern New Mexico

• Roy Rivas, HEN Team Lead• Claudia Saiz, CEO• Suzanne Quillen• Sabrina Martin

Eggtstra Special Effort RecognitionRoy Rivas – Presenter: Patient and Family Role in Reducing Pressure Ulcers, HRET Pressure Ulcer Bootcamp, August 2013

Alta Vista Regional Hospital100% data submission/ meets project goals for 80% of topics

• Jackie Anderson, HEN Team Lead• Melinda Carson Bailey• Angela Barela• Alice Elliott• Alice Padilla• Desiree Brown• Connie Trujillo• Julie Gorwoda

Carlsbad Medical Center

• Billie Fleming, HEN Team Lead• Clara Hargrove • Misty Harless • Debbie Janes • Shannon Anaya • Patricia Aldaz • Connie Shofner• Kris Armendariz • Faith Johnston

• Meghan Van Natta • Dianna Nicholls • Bridgett Sanchez • Claude Powell • Bryan Rayroux • Nicole Chavez• Joy Bennett• Teresa Gauntt • Chad Campbell, CEO

• Top Performer for NM HEN: 100% data submission/meets project goals for 100% across the board

• Top Performer Readmissions

Eggtstra Special Effort RecognitionBillie Fleming – Panel Presenter: Transforming Patient Care at the Bedside and Beyond, Albuquerque, March 2013

CHRISTUS St. Vincent Regional Medical Center

• George Wenner, HEN Team Lead• Andrew Tarnow• Antonia Dean• Cleo Fowler• Deborah Wallace• Pat Collins• Russell Stowers• Bruce Tassin, CEO• Jane McMillan• Suzanne Burlone

• 100% data submission

• Top Performer Readmissions

Cibola General Hospital

• Carmen Gutierrez, HEN Team Lead• Daniel Fenton• Maria Atencio• Glenna Yellowhead-Losito• Dr. Janice Shipley• Don Weidemann, CEO• Sherry Cruz

100% data submission

Eggtstra Special Effort Recognition• Carmen Gutierrez – Presenter: “Reducing Readmissions,” HRET Bootcamp, February 2014• Daniel Fenton – Presenter: “Bedside Handoffs,” Rural/CAH Webinar, June 2014;

Best CAUTI Campaign Idea “WTF: Why The Foley?”

Eastern New Mexico Medical Center

• Kim Hestand, HEN Team Lead• Deb Belyeu-Haeny• Jerri Citty• Karen Harkness• Kathleen Williams• Roger Kevin Sutherland• Stacey Sexton• Maridel Acosta-Cruz, CEO

Gerald Champion Regional Medical Center

• Kelli Dion, HEN Team Lead• Joan Eanes• Kathleen Olazaba• Don Shuwarger, MD• Jim Heckert, CEO• Leea Flores• Loretta Wolf

100% data submission/meets project goals for 80% of topics

Eggtstra Special Effort RecognitionJim Heckert – Presenter: HRET HEN Senior Leader Meeting, Phoenix, AZ, February 2013

Guadalupe County Hospital

• Senora L. Campos, HEN Team Lead • Christina R. Campos, CEO• John Lopez • Mandelyn Cordova • Dr. Randal Brown • Frank Tenorio

100% data submission/meets project goals for 80% of topics

Eggtstra Special Effort Recognition• Christina Campos – Presenter: “The Role of Leadership in Patient Family Engagement,” Attaining High

Reliability and Safety for Patients – Collaborating for Change Conference, Albuquerque, March 2014• Senora Campos – Presenter: Harm Across the Board Storyboard, Quality and Safety Roadmap/AHA Summit

Conference, San Diego, CA, July 2014; Presenter, “Hourly Rounding: Engaging Patients and Families,” Improvement Leader Fellowship Webinar, Dec 2013; Panel Presenter, “Lessons on Achieving High Reliability in Rural Settings,” Attaining High Reliability and Safety for Patients – Collaborating for Change Conference, Albuquerque, March 2014

HEALTHSOUTH Rehabilitation Hospital

• Sandra Cordova, HEN Team Lead• Sylvia Kelly, CEO• Veronica Gadomski• Sandra Lapointe

Holy Cross Hospital

• Linda Chase, HEN Team Lead• Loretta Ortiz y Pino, MD• Spencer Hamons• Lisa Clark• Steve Rozenboom• Anna Abeyta

• Peter Hofstetter(former CEO)

• Renee Sudborough• Ruby Luna

100% data submission

Eggtstra Special Effort RecognitionLinda Chase – Panel Presenter: “Successes with the HEN,” Transforming Patient Care At the Bedside and Beyond Conference, Albuquerque, March 2013; Presenter, Harm Across the Board Storyboard, Quality and Safety Roadmap/AHA Summit Conference, San Diego CA, July 2013; Panel Presenter: “Lessons on Achieving High Reliability in Rural Settings,” Attaining High Reliability for Patients – Collaborating for Change, Albuquerque, March 2104

Lea Regional Medical Center

• Cheryl Dingman, HEN Team Lead• Patrick Dunn• Shannon Salmon• Barbara Seay• Lisa Thompson• Mandy Wheeler• Timothy Thornell, CEO

• 100% data submission/meets project goals for 80% of topics

• Top Performer Readmissions

Lovelace Medical Center-Downtown

• Suzette Harris, HEN Team Lead• Laurie Bigham• Don Thompson• Sharon Miller

• Alice Underwood• Troy Greer, CEO• Samantha Schwartz

Lovelace Regional Hospital-Roswell

• Dawn Tschabrun, CEO, HEN Team Lead• Jennifer McIntier• Kim Webb• Karen Snow• Susan Sanders

100% data submission

Lovelace Westside Hospital

• Cheryl Sundheimer, HEN Team Lead

• Debbie Denson• Nancye Cole

• Lee Ann McIntyre• Farron Sneed, CEO• Patrizia Grob

Eggtstra Special Effort Recognition• Cheryl Sundheimer – Presenter: Falls Prevention, Improvement Leader Fellowship

(ILF) #7, September 2014 and ILF, Oklahoma City, OK, August 2014• Debbie Denson – Presenter: Falls Prevention, Improvement Leader Fellowship (ILF),

Oklahoma City, OK, August 2014

100% Data Submission

Lovelace Women’s Hospital

• Janet Abernathy, HEN Team Lead

• Joahnna Bell• Michele Cappel• Sheri Milone, CEO• Jane Ritter

• Dr. Abraham Lichtmacher• Diane Lane• Karen Van Harten• Vivian Silverman• Vicki Carr• Teri Kamphuis

Eggtstra Special Effort RecognitionJoahnna Bell – Presenter: Falls Prevention, Improvement Leader Fellowship (ILF), Oklahoma City, OK, August 2014

Mimbres Memorial Hospital

• Deb Paulk, HEN Team Lead• Robert Montoya• Pam Wade• Mayra Srader

Top Performer Readmissions

Mountain View Regional Medical Center

• Kelly Clark, HEN Team Lead• Gayle Nash• Lisa Kulkarne• Rodney Valdez• Julie Reyes• Yasmine Estrada• Denten Park, CEO• Kim Smetzer

100% data submission

Nor-Lea General Hospital

• BranDee Savell, HEN Team Lead• Kim Brown• Tami Leonard• David Shaw, CEO• Augusta Woody

• 100% data submission• Top Performer Readmissions

Eggtstra Special Effort RecognitionBranDee Savell – Presenter: “Data Strategies for Rural Hospitals,” CAH/Rural Affinity Group Webinar, September 2014

Rehoboth McKinley ChristianHealth Care Services

• Nancy Santiestaban, HEN Team Lead• Beatrice Nunez• Misty Leyba• Sidney Cowan

100% data submission/meets project goals for 80% of topics

Roosevelt General Hospital

• Tersa Bonifant, HEN Team Lead• Anne Carey• Anne Grayson, MD• LaDawna Brooks• Kenda Dickenson

• Larry Leaming, CEO• Iantha Hicks

100% data submission

San Juan Regional Medical Center

• Debra Brown, HEN Team Lead• Bonnie Adams• Barbara Duckett• Kristean Thorpe, MD

• Suzanne Smith• Rick Wallace, CEO• Ann Miller

• 100% data submission/meets project goals for 80% of topics

• Top Performer Readmissions

Sierra Vista Hospital

• Sue Wortman, HEN Team Lead• Palmer Greene• Cindy Johnson

• Terrie Vanskike• Michael Zimmerman, CEO• Rhea Ann Hazen

• 100% data submission• Top Performer Readmissions

Eggtstra Special Effort Recognition• Sue Wortman – Presenter: Harm Across the Board Storyboard, Quality and Safety

Roadmap/AHA Summit, San Diego, CA, July 2013• Cindy Johnson – Presenter: “Managing a Portfolio of Projects,” HRET Webinar, April,

2013