Montana Regional Meeting Glendive Medical Center AHA/HRET Hospital Engagement Network

1. Montana Regional Meeting Glendive Medical Center AHA/HRET Hospital Engagement Network Charisse Coulombe, MS, MBA, CPHQ; Senior Director, HEN Hospital Engagement Network Health Research & Educational Trust American Hospital Association

2. Hospital Engagement Network • ACA considerable focus on quality • Created the CMS Innovation Center • Public-private partnership • Set 40/20 goal • Tool: Hospital Engagement Networks • 26 contracts awarded • Contracted with 31 state and regional hospital associations • 1,600 + hospitals Hospital Leadership Clinicians & Front Line Staff (Teams) THE PATIENT

3. Partnership for Patients The 40/20 Goal • Keep patients from getting injured or sicker Reduce preventable hospital-acquired conditions by 40 percent 1.8 million fewer injuries to patients, with more than 60,000 lives saved over the next three years • Help patients heal without complication Reduce all hospital readmissions by 20 percent 1.6 million patients will recover from illness without suffering a preventable complication requiring re-hospitalization within 30 days of discharge

4. Progress to Date EEDs/OB Adverse Events • 36%: Average percent reduction in EED > =37 weeks and <39 weeks for 612 hospitals (68%) • 2,673 EEDs prevented (all hospitals) • $1.9 m Estimated cost savings for avoided EED NICU admissions (all hospitals) • Also tracking hard stop policies implemented across all birthing hospitals CAUTIs • 9%: AverageCAUTI percent reduction in all tracked units for 985 hospitals • 359 CAUTIs prevented (all hospitals) • $269,000 Estimated cost savings for avoided CAUTIs CLABSIs • 11%: AverageCLABSI percent reduction in all tracked units for 823 hospitals • 308 CLABSIs prevented (all hospitals) • $5.8M Estimated cost savings for avoided CLABSIs

5. Progress to Date ADEs and Falls • Focus area for all HENs and all of the states within our HEN • Participate in the Boot Camps! PRESSURE ULCERS • 2.52 Percent reduction inpatients with at least one Stage II or greater pressure ulcer for 399 hospitals • 8.18 Percent reduction inCMS HAC Pressure Ulcers for 367 hospitals • Need more data submission from our hospitals! • 34 Stage III/IV Pressure Ulcers prevented (all hospitals) • $1.4M Estimated cost savings for avoided Stage III/IV Pressure Ulcers SSIs • <0.81% Average surgical site infection rate (in hospital) for 808 hospitals • <1.26% Average SSI rate (within 30 days of procedure) for 752 hospitals

6. Progress to Date VTEs • 0.57Average percent reduction in Post-op PE/ DVT (AHRQ PSI 12) rate for 360 hospitals • 12.7Average percent reduction in Potentially Preventable VTE for 330 hospitals VAPs • 21 Averagepercent reduction in ventilator-associated pneumonia rate in ICU for 486 hospitals • 152 ICU VAPs prevented (all hospitals) • $6.5mEstimated projected cost savings for avoided ICU VAPs (all hospitals) READMISSIONS • 1.8 Average percent reduction for 30 day all cause readmission rate for 829 hospitals • 2.7 Average percent reduction for Heart Failure 30 day all cause readmission rate for 258 hospitals

7. Montana Summary Table

8. Montana Summary Table * Not enough monitoring data submitted to evaluate

9. What Data is Needed and How Much? • CMS’ focus is on outcome measures to track progress of the HENs • In order to be included in the HEN/state level analysis, need to submit at least 4 data points • Baseline and Monitoring periods are compared • Baseline is defined as pre-2012; if you started collecting data after January 2012, we need that data! • We will review your first month submitted and use as baseline reference to track your progress

10. Data Tools for Hospitals to Review Progress • Hospital Dashboard • Data Submission Status • Individual Measure Data • Run Charts • Hospital CEO Dashboard • Summary of the Hospital Dashboard • Both located under Reports in the Comprehensive Data System (CDS)

11. Intervention Tools Available • www.hret-hen.org has many resources • Topic specific change packages • Topic specific checklists • Reference articles • Previous recordings of webinars and meetings • Leadership, physician, patient/family engagement resources

12. Next Steps • Continue to work towards 40 percent harm reduction and 20 percent readmission reduction • Continue to submit data on your measures • Continue to track your progress on all topics through the progress reports • Continue to share your ideas and tools with others on the LISTSERVs • Continue to share your success stories with us, your states and your fellow hospitals

13. Thank You! • AHA/HRET HEN is proud of the accomplishments that have occurred to date and continue to look forward to accelerating the improvement across all topics! • We are here to support you in any way possible • General Email: hen@aha.org • Data Specific Questions: hendatasupport@aha.org • Check in with Casey Brewington!