GLPP HIIN Data Review: MICAH MICAH QN Meeting, August 2018 Prepared - - PowerPoint PPT Presentation

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GLPP HIIN Data Review: MICAH MICAH QN Meeting, August 2018 Prepared - - PowerPoint PPT Presentation

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GLPP HIIN Data Review: MICAH MICAH QN Meeting, August 2018 Prepared by: A Syrek GLPP HIIN Data Review: MICAH Please note: These slides use KDS ID; not to be confused with BCBSM ID Please ask Kristy or email keystone@mha.org if you need

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SLIDE 1

GLPP HIIN Data Review: MICAH

MICAH QN Meeting, August 2018

Prepared by: A Syrek

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SLIDE 2

Please note: ▪ These slides use KDS ID; not to be confused with BCBSM ID ▪ Please ask Kristy or email keystone@mha.org if you need your KDS

  • ID. (You can also find your hospital KDS ID in KDS)

GLPP HIIN Data Review: MICAH

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SLIDE 3

GLPP HIIN Overview – Top Performers

  • Highest 5 performing

areas out of 6

  • 6/6 over 20% reduction

*Data as of July 20, 2018 for Total Performance

Measure Baseline Rate Performance Rate Improvement

SSI-2b (HYST rate) 1.663 1.304 21.55% CLABSI-1b (SIR - ICU only) 0.970 0.761 21.57% CAUTI-2b (rate - ICU only) 1.364 1.060 22.29% SSI-1b (HYST SIR) 1.059 0.808 23.70% CAUTI-1b (SIR - ICU only) 1.051 0.797 24.12%

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SLIDE 4

GLPP HIIN Overview – Bottom Performers

  • Lowest 5 performing

areas out of 6

*Data as of July 20, 2018 for Total Performance

Measure Baseline Rate Performance Rate Improvement

PrU-1 (PSI-03) 0.280 0.352

  • 25.55%

SSI-2d (HPRO rate) 1.043 1.200

  • 15.04%

SSI-1d (HPRO SIR) 0.976 1.102

  • 12.88%

VAE-3a (VAC) 4.477 4.900

  • 9.45%

Falls-1 0.511 0.518

  • 1.27%
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SLIDE 5

MICAH – Top Performers

Measure Baseline Rate Performance Rate Improvement

SSI-1c (KPRO SIR) 5.727 1.578 72.45% SSI-2c (KPRO rate) 2.427 0.815 66.44% VTE-1 (PSI-12) 1.936 0.939 51.49% CDIFF-2 (CDI SIR) 0.720 0.374 48.01% Falls-1 1.235 1.020 17.44% *Data as of July 20, 2018 for Total Performance

  • Highest 5 performing

areas out of 12

  • 4/5 over 20% reduction
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SLIDE 6

MICAH - Falls with Injury (Falls-1)

1 2 3 4 5 6 7 8 4799 6804 6800 1293 6805 651 609 1300 1288 1141 1377 2481 1169 2487 1295 531 2860 580 3492 147 6799 745 1230 674 6801 618 6802 8000 1218 6806 6807 2485 504 1179 5034

RATE KDS ID Performance Rate Benchmark (1.020)

*Data as of July 20, 2018 for Total Performance (October 2016 – April 2018)

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SLIDE 7

MICAH - Hospital Onset Clostridium difficile Standardized Infection Ratio (SIR) (CDIFF-2)

0.2 0.4 0.6 0.8 1 1.2 1.4 745 1230 1179 674 2485 2487 609 1141 6799 1295 531 1300 651 1377 6801 147 504 2481 580 1218 618 6802 1288 6804 6800 6806 1293 1169 6805 2860 6807 3492 8000 4799 5034

RATE KDS ID Performance Rate Benchmark (0.3743)

*Data as of July 20, 2018 for Total Performance (October 2016 – December 2017)

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SLIDE 8

MICAH – Perioperative PE or DVT (VTE-1)

1 2 3 4 5 6 7 8 1300 1377 580 1218 6804 6799 1230 745 1288 651 1293 6801 1295 6806 1169 1141 504 531 1179 609 618 147 674 2481 6800 2485 6802 2487 6805 2860 6807 3492 8000 4799 5034

RATE KDS ID Performance Rate Benchmark (0.9389)

*Data as of July 20, 2018 for Total Performance (October 2016 – December 2017)

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SLIDE 9

MICAH – Surgical Site Infection Rate - Total Knee (SSI-2c)

0.5 1 1.5 2 2.5 3 3.5 4 4.5 6804 2860 4799 1377 147 618 6805 6800 1293 1218 1295 674 1300 6802 1230 6807 531 1288 580 609 2481 651 2485 6799 2487 6801 1169 1179 3492 6806 8000 745 1141 504 5034

RATE KDS ID Performance Rate Benchmark (0.8146)

*Data as of July 20, 2018 for Total Performance (October 2016 – December 2017)

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SLIDE 10

MICAH – Surgical Site Infection Standardized Infection Ratio (SIR) - Total Knee (SSI-1c)

1 2 3 4 5 6 7 8 9 4799 1377 147 504 6802 674 1230 6807 1288 580 1293 6800 1295 6805 1300 1169 1179 531 609 1218 618 651 2481 6799 2485 6801 2487 6804 2860 6806 3492 745 8000 1141 5034

RATE KDS ID Performance Rate Benchmark (1.577)

*Data as of July 20, 2018 for Total Performance (October 2016 – December 2017)

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SLIDE 11

MICAH – Bottom Performers

  • Lowest 5 performing

areas out of 9

Measure Baseline Rate Performance Rate Improvement

CDIFF-1 2.831 3.323

  • 17.37%

CAUTI-1a (SIR - all units) 0.374 0.513

  • 37.31%

CAUTI-2a (rate - all units) 0.495 0.816

  • 64.83%

SEPSIS-1 (PSI-13) 0.593 1.855

  • 212.80%

MRSA-1 0.023 0.242

  • 933.38%

*Data as of July 20, 2018 for Total Performance

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SLIDE 12

MICAH - Hospital Onset Clostridium difficile LabID Event (CDIFF-1)

10 20 30 40 50 60 6799 6801 1293 1230 531 1179 6805 745 674 2485 2487 504 1288 618 147 1300 1169 2481 580 609 6804 1377 651 6806 6800 1218 6802 1295 1141 2860 6807 3492 8000 4799 5034

RATE KDS ID Performance Rate Benchmark (3.322)

*Data as of July 20, 2018 for Total Performance (October 2016 – December 2017)

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SLIDE 13

MICAH - Catheter-Associated Urinary Tract Infection Standardized Infection Ratio (SIR) – All (CAUTI-1a)

1 2 3 4 5 6 7 6804 609 1230 6799 1141 6806 531 1218 1179 651 1288 1169 6801 1293 745 1295 504 1300 580 1377 618 147 674 2481 6800 2485 6802 2487 6805 2860 6807 3492 8000 4799 5034

RATE KDS ID Performance Rate Benchmark (0.5133)

*Data as of July 20, 2018 for Total Performance (October 2016 – December 2017)

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MICAH - Catheter-Associated Urinary Tract Infection Rate – All (CAUTI-2a)

5 10 15 20 25 30 35 1169 6801 6804 609 6799 1230 1141 531 1288 651 1179 1218 6806 1293 745 1295 504 1300 580 1377 618 147 674 2481 6800 2485 6802 2487 6805 2860 6807 3492 8000 4799 5034

RATE KDS ID Performance Rate Benchmark (0.8158)

*Data as of July 20, 2018 for Total Performance (October 2016 – December 2017)

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SLIDE 15

MICAH – Post-Operative Sepsis (SEPSIS-1)

2 4 6 8 10 12 14 16 1300 580 147 504 6804 1218 1230 745 1288 1179 1293 6801 1295 6806 1169 1141 1377 531 618 609 651 6799 674 2481 6800 2485 6802 2487 6805 2860 6807 3492 8000 4799 5034

RATE KDS ID Performance Rate Benchmark (1.855)

*Data as of July 20, 2018 for Total Performance (October 2016 – December 2017)

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MICAH – Methicillin-resistant Staphylococcus aureus LabID Blood Event (MRSA-1)

1 2 3 4 5 6 7 8 6799 1169 531 6806 6801 1218 1141 1230 1179 609 651 1288 6804 1293 745 1295 504 1300 580 1377 618 147 674 2481 6800 2485 6802 2487 6805 2860 6807 3492 8000 4799 5034

RATE KDS ID Performance Rate Benchmark (0.2417)

*Data as of July 20, 2018 for Total Performance (October 2016 – December 2017)

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SLIDE 17

MICAH PFE Status

28 30 30 33 20

5 10 15 20 25 30 35 PFE 1 - Planning Checklist Fully Implemented or No Scheduled Admissions PFE 2 - Shift Change Huddles Fully Implemented PFE 3 - Responsible Party Fully Implemented PFE 4 - PFAC/ Patient advisor on QI Team Fully Implemented PFE 5 - Governing Board Fully Implemented

PFE Status - MICAH Members

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MICAH PFE Status

17 30 30 33 20 4 5 5 2 9 3 6 11 5 10 15 20 25 30 35 PFE 1 - Planning Checklist PFE 2 - Shift Change Huddles PFE 3 - Responsible Party PFE 4 - PFAC/ Patient advisor on QI Team PFE 5 - Governing Board

PFE Status - MICAH Members

Fully Implemented Partially Implemented Not Implemented No scheduled admissions

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GLPP HIIN Data Dashboard

PUBLIC Dashboard

  • Data will be blinded utilizing KDS ID
  • Dashboard will shared in the near future
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BCBSM PG5 P4P Updates

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BCBSM PG5 CAH Current Benchmarks

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Updated PG5 CAH Baselines

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Updated PG5 CAH Baselines

Baselines are now 1 year in total and all 3 are the same

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Updated PG5 CAH Baselines

Hospitals will be scored on their numerators (incidents), not their rate.

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SLIDE 25

Updated PG5 CAH Baselines

Falls with Injury For hospitals with Sustained Zeros in their Baseline they will get an exception for 1 event.

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SLIDE 26

Updated PG5 NON-CAH Baselines

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SLIDE 27

P4P Storyboards – due by Nov. 1

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SLIDE 28

2018-19 PG5 P4P Storyboard link

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SLIDE 29

Upcoming Events

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SLIDE 30

Opioid Safety Initiative for ED teams

The MHA Keystone Center, as part of the GLPP HIIN, will soon launch an

  • pioid safety initiative for emergency department (ED) teams.

The project will replicate the Alternative to Opioids (ALTO) program, which was initially launched in Colorado and showed successful outcomes in reducing the administration of opioids in EDs. The MHA Keystone Center will host a launch meeting Sept. 11 at the MHA headquarters, Okemos. ED teams who are interested in participating should contact Brittany Bogan (bbogan@mha.org) at the MHA. Information about initiative expectations and recommended team composition is available online.

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2018 MHA Patient Safety & Quality Symposium September 19, 2018 Ann Arbor Marriott Ypsilanti at Eagle Crest 2018 MHA Keystone Fall Workshop October 23, 2018 JW Marriott, Grand Rapids

Register Now – Annual Symposium

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Advancing Fall and Injury Prevention Practices Workshop Wisconsin Hospital Association is hosting virtual attendance for Michigan members One-day conference October 10 Featuring: Dr. Patricia Quigley Registration Available

Fall and Injury Prevention Workshop

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PSO Safe Table focused on workforce safety

October 16

VisTaTech Center, Livonia Noon - 3 p.m. Registration will open soon

MHA Keystone PSO Safe Table

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SLIDE 34

Questions?

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SLIDE 35

Verify MI Care

  • https://verifymicare.org/
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SLIDE 36

keystonep4p@mha.org