Value Based-Purchasing (VBP)3/17/15

Lynda Caine, RN, BSN, MPH, CICInfection Prevention Officer

Overview• Value-Based Purchasing (VBP) for Healthcare-

Associated Infections (HAI)– Central Line-Associated Bloodstream Infections

(CLABSI)– Catheter-Associated Urinary Tract Infections (CAUTI)– Surgical Site Infections (SSI) for COLO procedures

• NH HAI 2013 Report Card• “Care Bundles” for Infection Prevention• Health and Human Services (HHS) National

Action Plan HAI 2020 Targets

What is Value-Based Purchasing?• The concept of value-based purchasing is that buyers

should hold health care providers accountable for both cost and quality of care

• Value-based purchasing brings together information on the quality of health care, including patient outcomes and health status, with data on the dollar outlays going towards health

• It focuses on managing the use of the health care system to reduce inappropriate care and to identify and reward the best-performing providers based on– How well they perform on each measure, or– How much they improve their performance on each measure

compared to their performance during a baseline period

Effective VBP Elements

• Standardized Performance Measurement– Is care safe, timely, efficient, effective, equitable

and patient-centered? Each element is critical• Transparency and Public Reporting• Payment Innovation – rethink reimbursement

based on performance• Informed Consumer Choice – to steer

consumers to high value providers

CMS Value-Based Purchasing Domain Weighting

State of New HampshireHEALTHCARE-ASSOCIATED INFECTIONS

2013 HOSPITAL REPORT

“Care Bundles” for Infection Prevention

• The Institute for Healthcare Improvement (IHI) is a main driver behind bundle-based care.

• Bundles are frameworks for addressing clinical healthcare conditions using evidence-based best practices.

• A bundle is a set of interventions, when grouped and implemented together, promote best outcomes with a greater impact than if performed individually.

• Care bundles aim to ensure that patients receive recommended treatments on a consistent basis.

Do Bundles Work?(Yes. Sometimes. But Not Always.)

INFECTION BUNDLE DOES THE BUNDLE WORK?

CLABSI Central Line-Associated Bloodstream Infection

Central Line Insertion Bundle Yes

CLABSI Central Line-Associated Bloodstream Infection

Central Line Maintenance Bundle

Yes

VAP Vent-Associated Pneumonia

VAP Bundle Yes

CAUTI Catheter-Associated Urinary Tract Infection

CAUTI Bundle Sometimes

CDI C difficile Infection C. diff Bundle Sometimes, But Not Always

CH Performance Standards for Hospital VBP Program

CH Performance Standards for Hospital VBP Program

NHSN Standardized Infection Ratio (SIR) “The Observed-to-Expected Ratio”

• To calculate the SIR, divide the number of our observed events by the number NHSN “expected” or “predicted” events

• For example:

6 observed CAUTI1.878 expected CAUTI

= SIR of 3.195 or greater than expected

RATE OF INFECTION/CATHETER DAYS FOR NH HOSPITALS

HOSPITAL # BEDS # ICU BEDS CAUTISFOLEY DAYS

RATE PER 1000 CATH DAYS SIR PT DAYS

DHMC 405 80* 23 10504 2.2 1.07 119653CONCORD 238 18 9 3158 2.8 2.38 62431

ELLIOT 281 40* 6 1942 3.1 2.53 62251CMC 235 20 6 3706 1.6 1.35 49708

SNHMC 148 20 2 1659 1.2 0.93 43568PORTSMOUTH 254 14 3 2646 1.1 0.74 36841

ST JOES 208 11 0 774 0 0 31451WENTWORTH 142 11 0 1329 0 0 31042

CHESHIRE 116 10 0 523 0 0 20097LAKES 110 10 0 1303 0 0 20036

EXETER 100 10 2 1480 1.4 1.04 18126

* INCLUDES PEDI ICU

Source: State of NH Healthcare-Associated Infections 2013 Hospital Report

CAUTI Bundle• Raise Staff awareness that CAUTIS are serious, cause patient harm and

increase the risk for multidrug resistant organisms and C. difficile• Renew focus on decreasing total catheter days in the ICU & housewide• ASK! Does the patient need a foley? (WTF)• Use straight caths and condom caths when possible• Insert catheter using aseptic technique• Secure catheter to the leg• Maintain closed, sterile system• Hand hygiene before and after touching catheters• Disinfect bedrails every shift• Do pericare twice a shift, once with ScrubStat• Use Fecal Containment Device to contain feces• Document reason for use of catheters• Discuss why catheters are in place during rounds• Audit use of the nurse-driven protocol for catheter removal• Remove the foley as soon as possible!• Discuss and de-brief all CAUTI events at the unit level with Staff, leadership

and infection prevention

HHS proposes new HAI Action Plan targets for 2020 On February 25, the U.S. Department of Health and Human Services (HHS) proposed 2020 targets for the National Action Plan to Prevent HAIs: Roadmap to Elimination (NAPHAI). The proposed targets were established by a steering committee of HAI prevention experts from federal agencies, with input from national stakeholders, including APIC. If finalized, the proposed targets would replace previous targets that expired in December 2013 and would establish January 2015 as the new baseline for all measures.

CH Performance Standards for Hospital VBP Program

NHSN CH Surgical Site Infections 2010 through 2014

ALOS for CH COLO SSIs Patients 2013 = 23.4 days

Average Length Of Stay (ALOS) FOR ALL COLO PATIENTS 2013 = 14.12 DAYS

Joint Commission Project:“7S Bundle” to Reduce Colorectal SSIs

Joint Commission Participants

Joint Commission Project“7S Bundle” to Reduce Colorectal SSIs

• Surgical site infections (SSIs) are the second most common healthcare-associated infection (HAI)

• SSI rates are disproportionately higher among patients following colorectal surgeries

• Resulting SSIs are known to have significant patient complications with adverse clinical and economic impact

• Preventing colorectal SSIs is a complex problem with multiple variables specific to patients and patient populations, institutional factors, surgical practice and process

• Participating hospitals used Lean, Six Sigma, and change management methods to understand why infections were occurring at their facilities and how to prevent them

• Participants focused on improving the care received by colorectal surgical patients, from preadmission to 30-days after surgery

Source: http://www.centerfortransforminghealthcare.org/assets/4/6/SSI_storyboard.pdf

Joint Commission Project Results

• After two-and-a-half years, there was an overall reduction in superficial incisional SSIs by 45 percent and in colorectal SSIs by 32 percent

• Participants attained cost savings of more than $3.7 million for the 135 estimated colorectal SSIs avoided during the project period

• Applying the reduction in SSIs to the annual case load of colorectal surgeries at participating hospitals suggests that they will experience 384 fewer SSI cases and save $10.6 million per year as the result of this work

Source: http://www.centerfortransforminghealthcare.org/assets/4/6/SSI_storyboard.pdf

Mayo Clinic – No “Silver Bullet”

“7S Bundle” to Reduce Colorectal SSIs

1. SAFETY – is the Operating Room safe?2. SCREEN – do we screen for patient risk factors and

presence of MRSA and MSSA?3. SHOWERS – do we have patients cleanse their body the

night before and the morning of surgery with CHG?4. SKIN PREP – are we prepping the skin with CHG?5. SOLUTION – do we irrigate with normal saline?6. SUTURES & WOUND PROTECTORS – do we use wound

protectors?7. SKIN CLOSURE – do we seal the incision or cover it with

an antimicrobial dressing to prevent contamination?

SHEA: Strategies to Prevent Surgical Site Infections in Acute Care Hospitals 2014 Update

1. Administer antimicrobial prophylaxis according to evidence-based standards and guidelines

2. Do not remove hair at the operative site unless the presence of hair will interfere with the operation

3. Control blood glucose during the immediate postoperative period for surgery patients

4. Maintain normothermia (temperature of 35.5°C or more) during the perioperative period

5. Optimize tissue oxygenation by administering supplemental oxygen during and immediately following surgical procedures involving mechanical ventilation

6. Use alcohol-containing preoperative skin preparatory agents if no contraindication exists

7. Use impervious plastic wound protectors for gastrointestinal and biliary tract surgerySource: AJIC Vol. 42 No.8 pages 823

Conclusion

• Value-based purchasing is a necessary catalyst for transforming the health care delivery system and getting to the goal of a high quality and affordable system

Resources

• http://nursingpathways.kp.org/national/quality/infectioncontrol/toolkit

• http://www.centerfortransforminghealthcare.org/assets/4/6/SSI_storyboard.pdf

• http://www.apicmn.org/2011%20Presentations/004b%20Colorectal%20SSI%20Reduction%20-%20Dr%20Robert%20Cima.pdf

• http://www.qualityreportingcenter.com/wp-content/uploads/2015/02/IQR-FY2017_VBP-Domain-Weighting-Infographic.pdf