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 your KDS ID. (You can also find your hospital KDS ID in KDS)
GLPP HIIN Overview – Top Performers • Highest 5 performing areas out of 6 • 6/6 over 20% reduction Baseline Performance Measure Rate 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% *Data as of July 20, 2018 for Total Performance
GLPP HIIN Overview – Bottom Performers • Lowest 5 performing areas out of 6 Baseline Performance Measure Rate 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% *Data as of July 20, 2018 for Total Performance
MICAH – Top Performers • Highest 5 performing areas out of 12 • 4/5 over 20% reduction Baseline Performance Measure Rate 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
MICAH - Falls with Injury (Falls-1) 8 7 6 5 4 RATE Performance Rate 3 Benchmark (1.020) 2 1 0 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 KDS ID *Data as of July 20, 2018 for Total Performance (October 2016 – April 2018)
MICAH - Hospital Onset Clostridium difficile Standardized Infection Ratio (SIR) (CDIFF-2) 1.4 1.2 1 0.8 RATE Performance Rate 0.6 Benchmark (0.3743) 0.4 0.2 0 745 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 KDS ID *Data as of July 20, 2018 for Total Performance (October 2016 – December 2017)
MICAH – Perioperative PE or DVT (VTE-1) 8 7 6 5 4 RATE Performance Rate 3 Benchmark (0.9389) 2 1 0 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 KDS ID *Data as of July 20, 2018 for Total Performance (October 2016 – December 2017)
MICAH – Surgical Site Infection Rate - Total Knee (SSI-2c) 4.5 4 3.5 3 2.5 RATE Performance Rate 2 Benchmark (0.8146) 1.5 1 0.5 0 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 KDS ID *Data as of July 20, 2018 for Total Performance (October 2016 – December 2017)
MICAH – Surgical Site Infection Standardized Infection Ratio (SIR) - Total Knee (SSI-1c) 9 8 7 6 5 RATE Performance Rate 4 Benchmark (1.577) 3 2 1 0 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 KDS ID *Data as of July 20, 2018 for Total Performance (October 2016 – December 2017)
MICAH – Bottom Performers • Lowest 5 performing areas out of 9 Baseline Performance Measure Rate 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
MICAH - Hospital Onset Clostridium difficile LabID Event (CDIFF-1) 60 50 40 30 RATE Performance Rate Benchmark (3.322) 20 10 0 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 KDS ID *Data as of July 20, 2018 for Total Performance (October 2016 – December 2017)
MICAH - Catheter-Associated Urinary Tract Infection Standardized Infection Ratio (SIR) – All (CAUTI-1a) 7 6 5 4 RATE Performance Rate 3 Benchmark (0.5133) 2 1 0 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 KDS ID *Data as of July 20, 2018 for Total Performance (October 2016 – December 2017)
MICAH - Catheter-Associated Urinary Tract Infection Rate – All (CAUTI-2a) 35 30 25 20 RATE Performance Rate 15 Benchmark (0.8158) 10 5 0 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 KDS ID *Data as of July 20, 2018 for Total Performance (October 2016 – December 2017)
MICAH – Post-Operative Sepsis (SEPSIS-1) 16 14 12 10 8 RATE Performance Rate 6 Benchmark (1.855) 4 2 0 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 KDS ID *Data as of July 20, 2018 for Total Performance (October 2016 – December 2017)
MICAH – Methicillin-resistant Staphylococcus aureus LabID Blood Event (MRSA-1) 8 7 6 5 4 RATE Performance Rate 3 Benchmark (0.2417) 2 1 0 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 KDS ID *Data as of July 20, 2018 for Total Performance (October 2016 – December 2017)
MICAH PFE Status PFE Status - MICAH Members 35 33 30 30 30 28 25 20 20 15 10 5 0 PFE 1 - Planning Checklist PFE 2 - Shift Change Huddles PFE 3 - Responsible Party PFE 4 - PFAC/ Patient PFE 5 - Governing Board Fully Implemented or No Fully Implemented Fully Implemented advisor on QI Team Fully Implemented Scheduled Admissions Fully Implemented
MICAH PFE Status PFE Status - MICAH Members 35 33 30 30 30 25 20 20 17 15 11 9 10 6 5 5 4 5 3 2 0 0 0 0 0 0 0 0 PFE 1 - Planning Checklist PFE 2 - Shift Change PFE 3 - Responsible Party PFE 4 - PFAC/ Patient PFE 5 - Governing Board Huddles advisor on QI Team Fully Implemented Partially Implemented Not Implemented No scheduled admissions
GLPP HIIN Data Dashboard PUBLIC Dashboard • Data will be blinded utilizing KDS ID • Dashboard will shared in the near future
BCBSM PG5 P4P Updates
BCBSM PG5 CAH Current Benchmarks
Updated PG5 CAH Baselines
Updated PG5 CAH Baselines Baselines are now 1 year in total and all 3 are the same
Updated PG5 CAH Baselines Hospitals will be scored on their numerators (incidents), not their rate.
Updated PG5 CAH Baselines Falls with Injury For hospitals with Sustained Zeros in their Baseline they will get an exception for 1 event.
Updated PG5 NON-CAH Baselines
P4P Storyboards – due by Nov. 1
2018-19 PG5 P4P Storyboard link
Upcoming Events
Opioid Safety Initiative for ED teams The MHA Keystone Center, as part of the GLPP HIIN, will soon launch an opioid 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.
Register Now – Annual Symposium 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
Fall and Injury Prevention Workshop 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
MHA Keystone PSO Safe Table PSO Safe Table focused on workforce safety October 16 VisTaTech Center, Livonia Noon - 3 p.m. Registration will open soon
Questions?
Verify MI Care • https://verifymicare.org/
keystonep4p@mha.org
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