Cohort 2 + 3+ 4 Coaching Call Cohort 9 October 15, 2014 Coaches: Tracy Rutland Jean Allred Jan Ratterree Lynne Hall

Cohort 2 + 3+ 4 Coaching Call“Cohort 9”

October 15, 2014Coaches:

Tracy RutlandJean Allred

Jan RatterreeLynne Hall

Learn. Act. Improve. Spread. Keep the Drum Beat Going.33

2014 OAT Survey Reminder October 24

• Survey Link Disturbed week of September 29th• Comparative survey – No changes in questions from the 2013!• Suggested list for gathering input will be included for each

domain• Due by October 24th • Summary and comparisons back to the hospitals in November• Hospitals completing the OAT on time will receive 5 points

toward their Leader’s Circle score


Best Practice Snapshot

• Answers will be used for final HENRecognition Program and Leader’s Circle Designation

• Failure to submit one survey per hospital will result in the loss of 5 points in the Recognition Program

• Due Date Friday, October 31 @ midnight• http://survey.gha.org/n/BPSS42014.aspx.

• Think of it this way Your HEN Option Year 1 Graduation Selfie

http://survey.gha.org/n/BPSS42014.aspx


NOVI reporting of C. difficile

• Begin surveillance/collection of data October 1• Place October data into GHA Manual Data Entry by November

15th

• Contact Jan Ratterree with any questions related to data collection surveillance and/or reporting into NOVI– (770)-240-4518– [email protected]

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What is required in Manual Data Entry to obtain accurate data:

• Numerator:– The number of C. difficile positive specimens in patients with specimen

collection day beginning with > 3 days after admission to the facility (i.e., on or after day 4).

• Important Numerator Definitions:– A + test for C. difficile is defined as:

• A positive laboratory test result for C. difficile toxin A and/or B, OR,• A toxin-producing C. difficile organism detected by culture or other

laboratory means performed on a stool sample.– Do not report a Duplicate toxin-positive laboratory

• (+) C. difficile toxin test result with prior (+) in ≤ 2 weeks in same patient and same location

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What is required in NOVI to obtain accurate data:

• Denominator:– Total number of Patient Days (do not count NICU and Well Baby)

– A daily count of the number of patients in the facility inpatient units during a time period. To calculate patient days, for each day of the month, at the same time each day, record the number of patients. At the end of the month, sum the daily counts and enter the total.

– If patient days are available from electronic databases, these sources may be used as long as the counts are not substantially different (+/_5%) from manually-collected counts

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What is required in NOVI to obtain accurate data:

• Denominator:– We are following inpatients

• A patient whose date of admission to the facility and the date of discharge are different calendar days.

• Note: A patient who is admitted to an inpatient location as an “observation” patient is identified as an inpatient on the first and subsequent days for the purposes of surveillance.

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Readmissions Data

2010 (Base-line)

11Q1 11Q2 11Q3 11Q4 12Q1 12Q2 12Q3 12Q4 13Q1 13Q2 13Q3 13Q4 14Q10.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

20.0%

0

20

40

60

80

100

12030 Day Readmission Rate- Medicare Only


Progress

• Harms Prevented– All HEN Initiative Harms exc. Readmission = 11,414

• Harms per day reduced by 38%– All Readmission = 6,799

• Readmissions per day reduced by 17%– Total Harms Prevented = 18,213

• Dollars Saved from baseline– All HEN Initiatives Harms exc. Readmission = $42,564,288– All Readmissions = $66,686,860– Total Dollars Saved through harm prevention = $109,251,148

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Improvement Rates Summary

• Post Operative PE/DVT PSI-12 19.13%

• CAUTI (CMS HAC6) *16.9%

• Sepsis PSI-13 16.9%• ADE-Glycemic Control

**10.43% • ADE-Anticoagulant

Control **@0.9% (well below benchmark)

• CLABSI SIR 9.82%

Hits!• Early Elective Delivery 98%• Pressure Ulcers PSI-3

Medicare only 42.40%• Pressure Ulcers Stage II

33.13%• CLABSI ICU 31.19%• SSI Hysto SIR* 24.9%• Vascular Catheter-Associated

Infection (CMS HAC 7) 23.1%

Hits are meeting 40/20 percent improvement from baseline or national benchmarks *2011 baseline **2013 baseline


Improvement Rates Summary

Misses• C-Diff Rate • Revised CAUTI Codes 996.64 and 599.0

(HAC26) • CAUTI SIR • CAUTI SIR (from NHSN) • CAUTI Utilization Ratio-General Units • CAUTI Utilization Ratio-ICU • CAUTI device utilization ratio (NHSN) • CAUTI Rate-ICU per 1,000 Catheter Days • CAUTI Rate-General units per 1,000

Catheter Days • CLABSI SIR (from NHSN)• CLABSI Utilization Ratio-General Units • CLABSI Utilization Ratio-ICU • CLABSI device utilization ratio (NHSN)

• CLABSI Rate-General Units per 1,000 Central Line Days • Falls and Trauma (CMS HAC 5) • Falls with Injury (NDNQI) • Sepsis Length of Stay • Sepsis Mortality Rate • Birth Trauma Rate - Injury to Neonate (PSI 17) • Obstetric Trauma Rate--Vaginal Delivery with Instrument

(PSI 18) • Obstetric Trauma Rate- Vaginal Delivery wo Instrument (PSI

19) • 30-Day Readmission Rate - Hospital Wide Readmission Rate

(CMS Definition) • 30-Day Readmission Rate - Medicare Only • Medicare FFS 30-Day All-Cause Readmissions • SSI: Colon • SSI: Hip Replacement • SSI: Knee Replacement

• SSI Colon Surgery SIR (NHSN) • Infection-related Ventilator-Associated Complication • Observed Rates for VACs- NHSN Definition • Probable VAP

Misses are not meeting 40/20 percent improvement from baseline or national benchmarks


Trending Better in CAUTI and CLABSI


Surgical Site Infection

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HAC – NOVI data entry










“It’s a wonderful life” and the HEN Project

• Consider the past 3 years without the HEN– What has made the difference

for your hospital– Tell the “HEN story” for your

hospital


Cohort “9” – Safety Across the Board

• Share additional successes on any HEN Topic

• Best Practice Implementation questions?

• Any questions/comments regarding measures?


Don’t Stop Now

What does that mean if you stop making improvements?

•Another 3,472 avoidable harms will happen in Georgia before

the end of the year

–Costing more than $12.8 million

•Almost 8,266 avoidable readmissions will happened before the

end of the year

–Costing $80 million


Upcoming Events

• Next Cohort Coaching Call: Not Scheduled• OB Adverse Event Affinity Webinar: October 22 @ 11 am• Data Submission – Aug. Due 10/15 / Sept. Due 11/15

ADE’s including INR, BG, and Opioids Falls with injury VTE-6 (due once a quarter) HAI (if not submitting via NHSN) include CDI EED if applicable

• GHA Annual Meeting November 13-14• HEN Celebration Webinar scheduled for November 19


EVALUATION

Remember Complete the evaluation for today’s Cohort “9” Coaching Call!

Documents

Cohort 2 + 3+ 4 Coaching Call Cohort 9 October 15, 2014 Coaches: Tracy Rutland Jean Allred Jan Ratterree Lynne Hall