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North Dakota Hospital Engagement Network

North Dakota Hospital Engagement Network . November 7, 3013. Trailer of “ Upcoming Events”. Option Year Information. CMS has notified AHA/HRET HEN of their intent to enter into an option year Contingent on approval of updated technical & business proposal for 2014 statement of work.

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North Dakota Hospital Engagement Network

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  1. North Dakota Hospital Engagement Network November 7, 3013 Trailer of “Upcoming Events”

  2. Option Year Information • CMS has notified AHA/HRET HEN of their intent to enter into an option year • Contingent on approval of updated technical & business proposal for 2014 statement of work. • Proposal sent to CMS as of November 4th.

  3. What CMS wants for option year • Recruitment: • Retain current participants with renewed signed commitment by CEO/Authorized senior leader • Add new hospitals • Topics: • Continued improvement in 10 areas • New emphases in some of the 10 areas: • CAUTI in ED • 2 focused OB topics • Expansion of CAUTI/CLABSI to all units • Multiple surgical settings in SSI • VTE in medical and surgical settings

  4. What CMS wants for option year • New topic area: • Healthcare Disparities • (Clarification as to extent of requirements and measurements to this topic are pending…)

  5. What CMS wants for option year • Data • Continued submission of data from participants (Goal – 80% or greater hospitals reporting) • Transition to standardized measures where possible • CLABSI and CAUTI – All units, including NICU and specialty units • ADE • Opioid (EOM - ADE 111) • Hypoglycemia (EOM – ADE 13) • Anticoagulation (EOM – ADE 12,14)

  6. What CMS wants for option year • Data – new measures: • CAUTI utilization ratio (NHSN definition) (EOM TBD) • # Indwelling catheter days / # patient days • OB Hemorrhage / Pre-Eclampsia (EOM TBD) • Any maternal patient receiving more than 3 units of any blood product; • Any maternal patient with a postpartum length of stay > 3 days for vaginal delivery and 5 days for C-section • Any maternal patient admitted to ICU

  7. What CMS wants for option year • Data – new measures: • VTE • All surgical patients • CMS recommends AHRQ PSI 12 (EOM – VTE 105) and CMS JC VTE – 6 (EOM – VTE 104) • SSI • Multiple surgical classes or procedures (4 our of 5) EOM – SSI 88,89) • Colon • Hysterectomy • Knee replacement • Hip replacement • Cardiac surgeries

  8. AHA/HRET HEN Team Priorities • Reduce CAUTI and expand into the Emergency Room • Document plans to work with QIOs, AAA, etc. • Create readmission campaign plan • Create education plan to include expanded and optional areas: (e.g., sepsis, c-diff, MRSA, antimicrobial stewardship, airway safety, failure to rescue, culture of safety, etc.)

  9. AHA/HRET HEN Team priorities • Work to align with national measures for all hospitals, including required measures: • CAUTI: urinary catheter utilization / ratio • CAUTI: All Tracked Units and ICU • ADE: opioid, hypoglycemic and anticoagulants measures • VTE: all surgical patients • SSI: multiple classes of surgery

  10. ND HEN plans for 2014 • Data alignment: • Review organization-defined measures – do numerator/denominator align with any EOM measures? • If not, will you consider moving toward a standard measure definition? • Will be included in statewide summary data; • Outcomes will be able to meet benchmarks

  11. ND HEN plans for 2014 • Focus on metrics that measure actual harm, e.g., number of injuries due to falls rather than number of falls with/without injury • Consolidate metrics so that at least 80% of hospitals submit data using same definitions • Offer strategies/Lean training to individual hospitals in regards to streamlining data gathering and submission

  12. ND HEN plans for 2014 • Continue to provide support in implementation of best practices; utilizing peer-to-peer support by facilitating regional small group meetings, etc. • Build on developing leadership “will” and support of improvement efforts. • Continue to disseminate quarterly CEO reports

  13. ND HEN plans for 2014 • Increase staff resources to support state HEN activities • Continue data submission into CDS • Continue/enhance one-on-one coaching, if warranted and/or requested • Continue promoting HRET-sponsored education • Continue facilitating ND-sponsored education and newsletter • Provide travel expenses to HEN-sponsored events, depending on funding (?)

  14. Movie genres for 2014…which category will your hospital team be in? Any questions? Action Comedy Documentary Epic and historical Fantasy Horror Live performances

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