National Priorities Improving Care for Individuals and Communities

1. National Priorities Improving Care forIndividuals and Communities OFMQ Hospital Improvement Team

2. Following the presentation the participant will be able to: • Summarize National priorities alignment with QIO work • Describe hospital HAI reporting initiatives, current and immediate future • Demonstrate ability to join OFMQ’s HAI Reporting group in NHSN

3. Activities that shape our new work • National Quality Strategy • Six priorities: safer care, coordinated care, person- and family-centered care, preventive care, community health, making care more affordable • Partnership for Patients • QIO initiatives can support your commitment • Adverse drug events, CAUTI, CLABSI, patient and family engagement

4. The Quality Improvement Organization Program has evolved • Bold improvement goals • Transformation at the systems level • Patient-centered approach • All improvers welcome • Everyone teaches and learns (“All teach, all learn”) • August 1, 2011 through July 31, 2014 • This material was prepared by Oklahoma Foundation for Medical Quality, the Medicare Quality Improvement Organization for Oklahoma, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.

5. How the Work is Done • Learning and Action Networks (LANs) • Providing technical assistance • Share what we learn with all

6. Strategic “Aims” Beneficiary and family-centered care Improving individual patient care Integrating care for populations and communities Improving health for populations and communities

7. Beneficiary and Family-Centered Care • Quality of Care Reviews • Early discharge reviews • National center for Medicare Beneficiary complaints

8. Improve Individual Patient Care • Hospital inpatient and outpatient quality reporting and improvement assistance (“core measures”) including critical access hospitals • Technical assistance • Training on measures • Assistance with reporting tools • WebEx or teleconferences for hospitals on use of tools, reporting deadlines, etc. • Reminders for meeting reporting deadlines • Opportunity to join OFMQ-HAI group on NHSN in order for us to better support you

9. Improve Individual Patient Care • Reducing healthcare-associated infections • The QIO will convene a learning and action network to focus on reduction of CLABSI, SSI, CAUTI, and CDI in hospitals • CAUTI- CUSP Training and methodology • Perform and Report monitoring of hand hygiene • Identify high-performing units (low infection rates) to serve as mentors to targeted hospitals • Share your successes with others • Report to NHSN and share results with OFMQ

10. OFMQ HAI Prevention Website www.ofmq.com/hai

11. How to Join the HAI List Serve • Open a new email message from the inbox you wish to receive HAI list postings. • Enter hai-subscribe@list.ofmq.com in the TO: field. • Enter ‘subscribe' in the subject field. • Click Send.

12. OFMQ would like to see your NHSN data • We will provide individual facility feedback on request • We will aggregate data as it is reported and provide feedback about Oklahoma performance • Use data to drive Learning & Action Networks • We help will insure timeliness with mandatory deadlines that might affect your payment • This material was prepared by Oklahoma Foundation for Medical Quality, the Medicare Quality Improvement Organization for Oklahoma, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.

13. NHSN Data is Secure with OFMQ • NHSN: Secure internet-based surveillance system; confidentiality protected under the Public Health Service Act: • “The information contained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306, and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)).”

14. NHSN Data is Secure with OFMQ QIO Statute: • 480.140 CFR(d)(2) • QIO is protected from providing patient or hospital/nursing home identification info (except under a few instances such as fraud/abuse) • Even if written permission is given to review data, second party cannot do anything with it • Non-discoverable under Freedom of Information Act • Second party cannot re-release it under regulatory rules

15. Requesting Data SharingBeginning January 2011 • Catheter Associated Urinary Tract Infection • Clostridium difficile Infection- Lab ID • MRSA Bacteremia • Hand Hygiene monitoring • Central Line Associated Blood Stream Infection (CLABSI) • Surgical Site Infection • HCW- Flu vaccination

16. Acute Care Hospital NHSN Reporting Current and Proposed

17. OFMQ HAI Reporting Group Log into NHSN – NHSN Reporting Modules In Menu, choose, Group, Then choose Confer Rights: • Group Number 20954 • Password : Oklahoma2011 • Save changes, or accept- at the bottom of the page

18. Questions about HAI ? Donna Piatt dpiatt@okqio.sdps.org Gayla Middlestead gmiddlestead@okqio.sdps.org • This material was prepared by Oklahoma Foundation for Medical Quality, the Medicare Quality Improvement Organization for Oklahoma, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.

19. Integrate Care for Populations and Communities • Improve quality of care for Medicare patients through a comprehensive community effort designed to improve care for patients across the continuum of care and reduce readmissions following hospitalization

20. Technical Support for Care Transitions OFMQ supports Communities in two tracts • Those communities accepted into a formal care transitions program such as the ACA Section 3026 program- OFMQ support up to acceptance into formal program • Communities not eligible or not accepted into a formal program- ongoing support from OFMQ • Contact Elanor Wallis ewallis@ofmq.com

21. How to Join the Care Transitions List Serve • Open a new email message from the inbox you wish to receive HAI list postings. • Enter ct-subscribe@list.ofmq.com in the TO: field. • Enter ‘subscribe' in the subject field. • Click Send.

22. Interested in Doing More to Improve Care Transitions? • If your hospital is interested in working with the community to improve care of patients at transitions (transfers and discharge) and reduce unnecessary hospital admissions and readmissions, please contact: • Elanor Wallis • ewallis@ofmq.com • 405-302-3243

23. Questions? • This material was prepared by Oklahoma Foundation for Medical Quality, the Medicare Quality Improvement Organization for Oklahoma, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.