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1

Title BlockWelcome to the K-HEN 2.0

Monthly Update Webinar!

Agenda• Welcome!

• Data Update: Baseline Data – thank you!

– Where are we as a state by topic? Data Analysis

• Monitoring Data Update: upcoming deadlines

– Operational Assessment questions – survey monkey

sent 2/18 – deadline 2/29

• Update on Incentive Payments

• Fellowship Activity

• Listserv Registration

• Upcoming Events – IP Boot Camp, Quality

Conference

• Q&A

Data: Baseline

Thanks for submitting your data!

K- HEN goal = >70% hospitals submitting

baseline data by the deadline

K-HEN results = 99%! Thanks for helping

us knock it out

of the park!

4

ADE Measures

51

38

44

0

10

20

30

40

50

60

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

Excessive Anticoagulation with Warfarin - Inpatients

Hypoglycemia in Inpatients Receiving Insulin

Adverse Drug Events due to Opioids

HEN2-ADE-1a HEN2-ADE-1b HEN2-ADE-1c

All K-HEN Hosps Rate

All HRET Hosps Rate

# K-HEN Hosps Reporting

CAUTI SIR and Rate

42

43

44

45

46

47

48

49

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

CAUTI SIR - All Inpatient Units Excluding NICU (NHSN ONLY) CAUTI SIR - ICUs Excluding NICUs (NHSN ONLY)

HEN2-CAUTI-1a HEN2-CAUTI-1b

All K-HEN Hosps Rate All HRET Hosps Rate # K-HEN Hosps Reporting

0

10

20

30

40

50

60

70

80

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

CAUTI Rate - All Inpatient Units Excluding NICUs (ALL Facilities) CAUTI Rate - All ICUs Excluding NICUs (ALL Facilities)

HEN2-CAUTI-2a HEN2-CAUTI-2b

All K-HEN Hosps Rate All HRET Hosps Rate # K-HEN Hosps Reporting

CAUTI Utilization Ratio

0

5

10

15

20

25

30

Urinary Catheter Utilization Ratio - All Inpatient Units Excluding NICUs (ALL Facilities)

HEN2-CAUTI-3a

All HRET Hosps Rate All K-HEN Hosps Rate

CLABSI SIR and Rate

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

CLABSI Rate - All Inpatient Units (ALL Facilities) CLABSI Rate - All ICUs (ALL Facilities)

HEN2-CLABSI-2a HEN2-CLABSI-2b

All K-HEN Hosps Rate All HRET Hosps Rate

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

CLABSI SIR - All Inpatient Locations(NHSN Facilities)

CLABSI SIR - ICUs (NHSN Facilities)

HEN2-CLABSI-1a HEN2-CLABSI-1b

All K-HEN Hosps Rate All HRET Hosps Rate

CLABSI Utilization Ratio

0

5

10

15

20

25

Central line utilization ratio - All Inpatient Units (ALL Facilities)

HEN2-CLABSI-3a

All K-HEN Hosps Rate All HRET Hosps Rate

0

20

40

60

80

100

120

140

OB Trauma - Vaginal Delivery with Instrument (AHRQ PSI 18) OB Trauma - Vaginal Delivery without Instrument (AHRQ PSI 19)

HEN2-OB-1 HEN2-OB-2

All K-HEN Hosps Rate All HRET Hosps Rate

9.3

9.4

9.5

9.6

9.7

9.8

9.9

10

10.1

10.2

10.3

Early elective deliveries (PC-01, NQF 0469)

HEN2-EED-1

All K-HEN Hosps Rate All HRET Hosps Rate

Early Elective Delivery2013

Other OB Harm2011

Falls With Injury

0

0.5

1

1.5

2

2.5

Falls with Injury (NQF 0202)

HEN2-Falls-1

All K-HEN Hosps Rate All HRET Hosps Rate

Pressure Ulcer

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

Pressure Ulcer Rate, Stages 3+ (AHRQ PSI 03) Pressure Ulcer Prevalence, Hospital-Acquired-Stage 2+ (NQF 0201)

HEN2-PrU-1 HEN2-PrU-2

All K-HEN Hosps Rate All HRET Hosps Rate

HW 30 Day All Cause Readmissions

7.2

7.4

7.6

7.8

8

8.2

8.4

8.6

8.8

Readmission within 30 Days (All Cause)

HEN2-READ-1

All K-HEN Hosps Rate All HRET Hosps Rate

SSI SIR – Colon/Abdominal Hysterectomy

0

0.2

0.4

0.6

0.8

1

1.2

SSI SIR - Colon Surgeries (NHSN ONLY) SSI SIR - Abdominal Hysterectomies (NHSN ONLY)

HEN2-SSI-1a HEN2-SSI-1b

All K-HEN Hosps Rate All HRET Hosps Rate

SSI Rates

0

1

2

3

4

5

6

SSI Rate - Colon surgeries (ALL Facilities) SSI Rate - Abdominal hysterectomies (ALL Facilities)

SSI Rate - Total knee replacements (ALL Facilities)

SSI Rate - Total hip replacements (ALL Facilities)

HEN2-SSI-2a HEN2-SSI-2b HEN2-SSI-2c HEN2-SSI-2d

All K-HEN Hosps Rate All HRET Hosps Rate

VAE – VAC/IVAC

0

0.5

1

1.5

2

2.5

Ventilator Associated Condition (VAC) - ALL Facilities Infection-Related Ventilator-Associated Complication (IVAC) - ALL Facilities

HEN2-VAE-1 HEN2-VAE-2

All K-HEN Hosps Rate All HRET Hosps Rate

VTE

3.55

3.6

3.65

3.7

3.75

3.8

3.85

3.9

3.95

Post-Operative Pulmonary Embolism (PE) or Deep Vein Thrombosis (DVT) Rate (AHRQ PSI 12)

HEN2-VTE-1

All K-HEN Hosps Rate All HRET Hosps Rate

C. Difficile SIR and Rate

0

1

2

3

4

5

6

7

8

9

Standardized Infection Ratio (SIR) for patients with C. difficile (NHSN-submitting facilities only)

Facility-wide C. difficile Rate

HEN2-CDI-1a HEN2-CDI-1b

All K-HEN Hosps Rate All HRET Hosps Rate

Post Operative Sepsis

0

2

4

6

8

10

12

14

16

Postoperative Sepsis Rate

HEN2-SEPSIS-1a

All K-HEN Hosps Rate All HRET Hosps Rate

Data: Monitoring

Monitoring data – Ky. Quality Counts (KQC) site

ready for outcomes measures monitoring data

Process measures are in progress-We will be

Survey-Monkeying you AGAIN about process

measure choices

Contact Melanie or Dolores with questions

Remember, all monitoring data goes into KQC

www.hret-hen.org for Encyclopedia of Measures

– EOM is updated periodically

Goal: Monitoring data through February in KQC

counts by 3/15 for incentive and by 3/31 to stay

on track 20

Operational Assessment ?

Follow up to the Needs Assessment

Data will be queried quarterly

Current query via Survey Monkey is

due 2/29

Contact Donna Meador or Melanie

Moch for questions

Data – Incentive Updates

• Milestone 1 - 74 hospitals received

$500 for participation (to offset

additional data work), totaling

$37,000 to Kentucky Hospitals

• Milestone 2 – 51 hospitals to receive

$500 for submitting baseline data by

deadline, totaling $25,500 to

Kentucky hospitals

Action Leader Fellowship

23

• AHA/HRET in Partnership with IHI

• Content related to the science of improvement to

support your quality improvement (QI) teams to

drive change, basic and experienced levels

• Need to participate in live webinar in at least 8 of 10

webinars – we are on webinar #5

• Special consideration for Ky Fellows who are

attending the Quality Conference on 3/9 and will

miss the live webinar

We have 24 Fellows in progress in Kentucky!

Thank you for helping us build Quality Improvement

Capacity in Kentucky!

Listserv Information• Register for the listservs on HRET

website –http://www.hret-hen.org/inc/dhtml/listserv.dhtml

Adverse Drug Event (ADE)

Data Analytics

Infections – includes CAUTI, CDI, CLABSI,

SSI, and VAE

Early Elective Delivery & OB Adverse Event

Other Harm – includes VTE, Airway Safety, Failure to Rescue,

Iatrogenic Delirium and Radiation Exposure

Patient & Family Engagement/Health Care Disparities

Pressure Ulcers & Falls

Readmissions

Rural/Critical Access Hospitals

Sepsis

Listservs – you might be missing out….

Falls: Hello Falls Champions,

A big thank you to Eve Brown from Henry May Newhall Hospital in Valencia, CA for

sharing her organization’s “Call Don’t Fall” video and handout used for partnering

with patients to prevent falls.

Attached you will find the handout and here is a link to the

video: https://www.youtube.com/watch?v=o7jVmrxjv2A

Thanks again for sharing! Jackie

Jackie Conrad RN, BS, MBA, RCC™| Improvement Advisor | Cynosure Health

Solutions

708-420-1130 (c) |jconrad@cynosurehealth.org

All In Saves Lives. www.cynosurehealth.org

Listservs – you might be missing out….

Pressure ulcers: Greetings Pressure Ulcer Champions!

What’s your secret to success in implementing monthly Pressure Ulcer Prevalence

Studies?

· Do you use exempt staff (managers, educators, clinical specialists) or Front line staff

or Both?

· What creative approaches have you used to provide the manpower to conduct the

visual inspection of every patient on the day of the study? Do you use orientees? Light

duty staff? Creative scheduling?

A free resource to consider is tapping into student nurses! Have you considered involving

students? Baccalaureate Nursing Students are prime candidates for assisting with or

independently conducting your prevalence studies as part of their research or quality

improvement curriculum. Share this article with your nursing instructors as a way to

integrate the student’s learning into your unit’s quality improvement

plan. https://www.medlineuniversity.com/DesktopModules/Documents/ViewDocument.

aspx?AddToLog=1&DocumentID=1239

Jackie Conrad RN, BSN, MBA, RCC™ | Improvement Advisor | Cynosure Health

Solutions 708-420-1130 | jconrad@cynosurehealth.org www.cynosurehealth.org

Wrap Up, Next Steps1. Complete monitoring data submission by

March 15

2. Go to Upcoming Events Tab on HRET

website for upcoming webinars• Next Fellowship is March 9 (same as Quality

Conference!)

• Next K-HEN Monthly Update webinar March 23

3. Kentucky Infection Prevention Boot Camp

March 8 & 9, Embassy Suites Hotel, Lexington

4. K-HEN Conference March 9 & 10, also Embassy Suites Hotel, Lexington

Do you have a Patient Safety Hero nominee?

Submit them to the K-HEN Website and be

recognized!

Q & A Session

Thank you for participating in the…

Race to Quality!

(Sprint /Marathon)