TCQPS Hospital Engagement Network: Determining our Metrics Data and Metrics Webinar

1. Partnership for Patients TCQPS Hospital Engagement Network: Determining our Metrics Data and Metrics Webinar Feb. 29 at 10:00 and Mar. 8 at 2:00 2012

2. Introductions • Terri Conner, PhD Project Manager, Nybeck Analytics • Lisa Kerber, PhD Data Manager, Nybeck Analytics

3. Summary of this Presentation Goals of Partnership for Patients by end of 2013 Purpose of metrics Data requirements for hospitals Our HEN’s currently proposed metrics How we arrived at the proposed metrics Timeline associated metrics Next steps for hospitals What the TCQPS HEN can do for your hospital Communication

4. Purpose of Metrics for PfP Goals of Partnership for Patients by End of 2013 Decrease hospital-acquired conditions by 40%, compared to 2010 Decrease preventable readmissions by 20%, compared to 2010 Purpose of Metrics Aid hospitals and Hospital Engagement Networks in planning and management Allow transparency on topics that can enable broader financial and political support for related programs Demonstrate that goals have been achieved

5. The 10 hospital-acquired conditions (HACs) for initial focus by the PfP are: Adverse drug events Catheter-associated urinary tract infections Central line-associated blood stream infections Injuries from falls and immobility Obstetrical adverse events Pressure ulcers • Surgical site infections • Venous thromboembolism • Ventilator-associated pneumonia • Preventable readmissions • In addition: • Safety culture • Leadership

6. Data-Related Requirements of Hospitals At least one process measure for each focus area (9 HACs, all-payer preventable readmissions) At least one outcome measure for each focus area Our goal is to have one numerator and one denominator for each metric Submit monthly data: Baseline Process and Outcome: 6-24 months (2010 and 2011) Initiative Process and Outcome: 12-24 months (2012 and 2013) Complete Hospital Survey on Patient Safety Culture at program onset and once every 12-18 months for duration of program, with at least a 60% response rate from each unit Attend TeamSTEPPS training and provide information on how tools in the model will help you achieve your goals (will receive CEs) Complete other surveys and interviews as needed

7. Quality Improvement: Why both Process and Outcomes Measures? • Structure measures assess the accessibility, availability, and quality of resources, such as health insurance, bed capacity of a hospital, and number of nurses with advanced training. • Process measures assess the delivery of health care services by clinicians and providers, such as using guidelines for care of mechanically ventilated patients. • Outcome measures indicate the final result of health care and can be influenced by environmental and behavioral factors. Examples include mortality, patient satisfaction, and improved health status.

8. QI Model* *Donabedian

9. Arriving at Proposed Metrics • Literature Review • Data Advisory Council • Comparison to other HENs’ Plans • TCQPS HEN Online Survey on Data and Metrics

10. Proposed Outcomes Table

11. Currently Proposed Outcomes Metrics CDC NHSN and/or state reported data: CAUTI: N CAUTI in unit/Total N catheter days CLABSI: (by unit) N CLABSI/Total N CL days SSI: hip & knee arthroplasties, CABG, colon, ab hysterectomies, vascular procedures, etc N pts with SSI/Total N pts with procedure VAP: CDC NHSN N VAP/N ventilator days

12. Currently Proposed Outcomes Metrics Calculated by hospital using claims/billing/financial data: All-Cause Readmissions If you are in Project RED, continue with the methods your hospital has already developed If you are not in Project RED, we are recommending that you focus on one or more core condition (AMI, PN, CHF) and calculate raw rates We also recommend that you include All Payer, not just Medicare patients N patients readmitted within 30 days/N patients discharged in prior month

13. Currently Proposed Outcomes Metrics Calculated by CMS with claims/billing/financial data: Hospital will replicate Injuries from falls and trauma N pts with diagnosis codes as secondary (2-9) with a POA of N or U, designated as CC or MCC/N discharges during time period Pressure ulcers N pts with diagnosis codes as secondary (2-9) with a POA code of N or U (707.23, 707.24)/N discharges during time period

14. Currently Proposed Outcomes Metrics (Continued) • VTE: NQF Incidence of potentially preventable VTE: • N Pts who receive no prophylaxis prior to VTE diagnostic test order date/N Pts who develop confirmed VTE during hospitalization • Obstetrical adverse events: NQF Incidence of birth trauma in elective deliveries < 39 wks • N babies with any birth trauma diagnosis/N babies with elective delivery between 37 and 39 weeks

15. Currently Proposed Outcomes Metrics (Continued) • ADE – IHI Random chart review; use of trigger tool*. 10 charts/q2wks for a total of 20 charts/mo • N of adverse drug events/N total doses • N ADEs by NCC MERP * Rozich et al. Qual Saf Health Care 2003;12:194-200.

16. Conferring Rights to TCQPS in NHSN THA Information: • Group Name: THA TCQPS • Group ID: 19288 • Group Joining Password: tcqpspfp

17. Currently Proposed Process Metrics CAUTI: 1. Compliance with educational program: N personnel who insert/maintain urinary caths and have proper training/N personnel who insert/maintain caths 2. Compliance with documentation of insertion and removal days Random audits N patients on unit with cath with proper documentation of insertion and removal dates/N patients on unit with cath in place 3. Compliance with documentation of indication for cath placement Random audits N patients on unit with cath with proper documentation of indication/N patients on unit with cath 4. Catheter Utilization Ratio: N catheter days/N patient days

18. Currently Proposed Process Metrics CLABSI: Adherence to bundle: N adherence/N total insertion Hand hygiene Skin prep – CHG Skin prep agent completely dried All 5 maximal sterile barriers used Sterile gloves, gown, cap, mask, drape SSI: Adherence to SCIP measures: N adherence/N surgical patients SCIP 1, 2, 3: Prophylactic abx SCIP 4: Glucose SCIP 6: Hair removal SCIP 9: Post op cath dc’d SCIP 10: Temp

19. Currently Proposed Process Metrics Injuries from falls and immobility Risk assessment on admission: Random chart review N Charts with risk assessment documentation/Total N Charts reviewed Pressure ulcers PU Prevention protocol: Random chart review N Charts with proper documentation of adherence/Total N Charts reviewed PU assessment on admission: Random chart review N Charts with PU assessment documentation/Total N Charts reviewed Preventable readmissions Discharge checklist: Random chart review N Charts with discharge checklist documentation/Total N Charts reviewed Medication reconciliation: Random chart review N Charts with unreconciled medications at discharge/Total N Charts reviewed

20. Currently Proposed Process Metrics (Continued) • Obstetrical adverse events: NQF Elective deliveries < 39 weeks: • N pts delivering between 37 and 39 weeks/N pts with elective deliveries

21. Currently Proposed Process Metrics (Continued) • VTE: Reportable to CMS • SCIP: VTE 1, 2 prophylaxis • N patients prophylaxis/N total patients • STK: VTE 1 prophylaxis • N patients prophylaxis/N total patients • VTE: • 1,2: prophylaxis • N patients prophylaxis/N total patients • 5: Discharge instructions • N patients discharge inst documentation/N total patients • VAP: NQF/IHI Adherence to vent bundle • HOB elevation; 2. Sedation; 3. TSB; 4. Pressure Ulcer and DVT prophylaxis • N pts with bundle documentation/N pts on Mech Vent

22. Currently Proposed Process Metrics (Continued) • ADE – IHI Medication Reconciliation: Admission, Transfer, Discharge • N pts with Med Rec documentation/N charts reviewed • N pts with Unreconciled medication/N charts reviewed

23. Proposed Process Table

24. Proposed Process Table

25. Expected Timeline Associated with Metrics March 2012: HEN works with hospital HAC teams to finalize metrics. March-April 2012: Hospital HAC teams gather baseline data as far back to 2010 as possible; HAI HAC teams allow TCQPS NHSN access. April-May 2012: TCQPS launches data portal and HAC teams submit baseline data. TCQPS will extract NHSN data. May-Dec 2012: HAC teams continue to gather and submit monthly data. July 2012-Dec 2013: HEN distributes reports to hospital HAC teams on a quarterly basis.

26. Next steps for your hospital • Complete our on-line survey on HAC measures? • Please contact Lisa Kerber at Lisa@nybeck.net; she will send you link to survey • Communicate to TCQPS historical performance in the 10 HACs • 2010-2011 • How do you currently measure the 10 HACs • Send in HAC Team forms, which describe your internal teams for each HAC. • How do you currently measure your safety culture? HSOPS? Other survey? How often?

27. What the TCQPS HEN and PfP Can Do for your Hospital • Regional face-to-face best practice sharing events annually • Peer-to-peer training opportunities • Leadership, Culture, Physician, Board & Pharmacy education & training • Annual stipend per hospital for travel to regional meetings

28. What else the TCQPS HEN and PfP Can Do for your Hospital • Monthly webinars/conference calls to discuss new ideas, barriers, processes, etc. • Partnership with other HENs & QIO to share information & best practices • Online Communities of Practice • Measure & track hospital performance • Site visits to participating hospitals to assist teams • Assist your hospital in reaching the PfP goals

29. Communication PfP Community of Practice: Register at http://www.healthcarecommunities.org/ TCQPS HEN Community of Practice: after registering for PFP and TCQPS HEN, then go to ‘Communities’ TCQPS HEN’s data portal--due early Spring 2012 www.texashospitalquality.org Questions? Contact: Terri Conner, PhD, at Nybeck Analytics, terri@nybeck.net, 512-796-1099