MHA Keystone Center MICAH QN Meeting – May 18, 2018
Agenda • ADEs due to Opioids measure • Sepsis measures a) Post-Operative Sepsis (PSI-13) b) Sepsis Mortality Rate • Falls with Injury measure • Person & Family Engagement • HRM – HIIN Reliability Measure • Upcoming Educational Opportunities
Data submission reminder – June 15 Data entry for the 2017-18 Blue Cross PG5 P4P program year (April 2017- March 2018 ) is June 15 – Final Scores for the program will come out via email in late June. This includes Manual Entry measures via KDS • ADE (All 3 - Anticoagulation, Hypoglycemia & ADEs due to Opioids) • Falls with Injury • Person & Family Engagement NHSN (Infection Measures) • C Diff • MRSA • CAUTI • CLABSI • VAE • SSI (through Q4 2017) Surgical Site Infection (SSI) data will include submission for April 2017-December 2017 . If you enter infection measures via NHSN please be mindful that the deadline for the Blue Cross program data submission is June 15 . This does not follow the usual NHSN deadline but is needed for the Blue Cross P4P program. If someone else at your facility enters these measures please notify them of this deadline for the BC P4P PG5 program. Reminder, If your hospital has already been clarified as ‘ineligible’ to collect a specific measure(s) then you do NOT need to enter those measures, that has not changed.
ADEs due to Opioids (ADE-4)
FAQ – ADE due to Opioids
Community Site Resources
Gap Analysis http://www.surveygizmo.com/s3/3220380/Great-Lakes-Partners-for-Patients-Gap-Analysis-Landing-Page
ADE due to Opioids PG5 has LOWER rates than PG1-4 and other hospitals in the HIIN for ADE related to Opioids
ADE due to Opioids
ADE due to Opioids Performance Data included: 2016 Q4 - 2018 Q1 Benchmark Period: 2016 Q4 - 2017 Q3 ADE - Opioids HIIN CAH Benchmark = 0.3023 MI IL WI GLPP Total CAH Number of CAH 35 38 40 113
Sepsis What is Sepsis? Sepsis is the body’s overwhelming and life -threating response to infection which can lead to tissue damage, organ failure, and death. Faces of Sepsis (sepsis.org) https://www.youtube.com/watch?v=12Qbnn6XfH0
datakoala@mha.org
Post-Op Sepsis (PSI-13)
PSI 13 Post-op Sepsis AHRQ Quality Indicators™ (AHRQ QI™) ICD -10-CM/PCS Specification Version 6.0 Patient Safety Indicator 13 (PSI 13) Postoperative Sepsis Rate July 2016 www.qualityindicators.ahrq.gov Provider-Level Indicator Type of Score: Rate DESCRIPTION Postoperative sepsis cases (secondary diagnosis) per 1,000 elective surgical discharges for patients ages 18 years and older. Excludes cases with a principal diagnosis of sepsis, cases with a secondary diagnosis of sepsis present on admission, cases with a principal diagnosis of infection, cases with a secondary diagnosis of infection present on admission (only if they also have a secondary diagnosis of sepsis), obstetric discharges, and cases with missing values as listed in denominator section.
https://www.cdc.gov/vitalsigns/sepsis/
GLPP Webinar: Recognize and Manage Sepsis in the Post-Acute Setting - December 19, 2017 https://community.mha.org/viewdocument/glpp-webinar-recognize-and-manage?CommunityKey=4ab0331c-9624-41ad-8c6c- 83734e9baf08&tab=librarydocuments
Sepsis Resources – Community Site
Post-Op Sepsis Rate INCREASING for CAH
Post-Op Sepsis Rate INCREASING for CAH
Sepsis Mortality
Sepsis Mortality
Sepsis Mortality Michigan CAH Only Data included: 2015 Q4 - 2016 Q3 Average = 17.8
Falls with Injury
NQF 0202
Injury levels (NQF 0202)
Falls with Injury PG5 has higher rates than PG1-4 and other hospitals in the HIIN for Falls with Injury
Falls with Injury
Falls Rate
Falls with Injury Performance Data included: 2016 Q4 - 2018 Q1 Benchmark Period: 2016 Q4 - 2017 Q3 Falls HIIN CAH Benchmark = 0.9281 MI IL WI GLPP Total CAH Number of CAH 35 38 40 113
CAH Benchmarks MI IL WI GLPP Total CAH Number of CAH 35 38 40 113
CAH Benchmarks MI IL WI GLPP Total CAH Number of CAH 35 38 40 113 2016 Q4 - 2017 Q3 Benchmark Period, All HIIN CAH • Falls = 0.9281 • ADE - Opioid-related = 0.3023
PFE Status - MICAH Members PFE Status - MICAH Members 40 35 35 30 32 29 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 advisor PFE 5 - Governing Board Fully Implemented or NA Fully Implemented Fully Implemented on QI Team Fully Implemented Fully Implemented
PFE Status - MICAH Members PFE Status - MICAH Members 40 35 30 25 No scheduled admissions 20 Fully Implemented Partially Implemented 15 Not Implemented 10 5 0 PFE 1 - Planning PFE 2 - Shift Change PFE 3 - Responsible PFE 4 - PFAC/ Patient PFE 5 - Governing Checklist Huddles Party advisor on QI Team Board
PFE Status - MICAH Members PFE Status - MICAH Members 40 35 30 25 No scheduled admissions 20 Fully Implemented Partially Implemented 15 Not Implemented 10 5 0 PFE 1 - Planning PFE 2 - Shift Change PFE 3 - Responsible PFE 4 - PFAC/ Patient PFE 5 - Governing Checklist Huddles Party advisor on QI Team Board
PFE Reminders/Updates • MHA Data Team will no longer copy comments month to month • Make a comment when you update your status - check for previous comments • We are seeing month after month comments of “In discussion” or “Goal in near future” carried on without meaningful, recent input • Good example of comments: Year Month PFE 1 - Planning Checklist PFE 1 - Comment 2017 6 Not Implemented We are working with Marketing to have the checklist placed in a new Patient admission booklet 2017 7 Not Implemented 2017 8 Not Implemented Marketing will have the checklist placed in a new Patient admission booklet in August 2017 2017 9 Fully Implemented
PFE Reminders/Updates • Only one month can be edited at a time for PFE • If you need records updated going back several months, notify MHA staff • “No Scheduled Admissions” is an option in the drop - down for PFE- 1; please do not submit “Not Implemented” if this is the case • Option was added June 2017; adjustments made by MHA staff on previous entries
HIIN Reliability Measure (HRM) • Instead of focusing on individual topic areas, the HRM was designed to gauge overall trends in adverse events for each hospital • HRM meant to address internal questions like: o Do we tend to have more adverse events in summer or winter? (Quarterly seasonality) o Are we seeing more infections of all types due to hand hygiene issues? (CAUTI, C.diff, etc.) o When we implemented a new “Speak Up” program, did overall events decline due to harms being avoided? • Ratio involving patient days not appropriate for small-volume facilities due to varying data sources & surveillance windows
Storyboard Improvement Activity
Sample Final Storyboard
PSO Update June 12: Noon – 3 pm PSO Safe Table focused on OB adverse events Grand Valley University – LV Eberhard Ctr, Grand Rapids June 20: 8 am – 4:30 pm PSO Root Cause Analysis & Action Training Bronson Methodist Hospital, Kalamazoo
CAH Falls Webinar – June 15, 1pm GLPP HIIN Essential Steps to Protect Patients from Injurious Falls in Acute & Critical Access Hospitals with Patricia Quigley, PHD June 15 1-2 pm (ET) https://zoom.us/meeting/register/b704955d9c75edf08c34be5db4a05ad8
Save the Date 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
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