2013 HEN WRAP UP 2014 QUALITY PREVIEW

All Hospital Engagement Network’s goal:

To Reduce Hospital Acquired Conditions by 40% and reduce

preventable readmissions by 20% by January 1, 2014.

ASHNHA Quality Review

• AHA HEN began in earnest May 2012• Combination of HEN and State Flex Funding supported all

Quality-related activities• Over 40 people traveled to the Improvement Leadership

Fellowship and Improvement Collaboratives• Mentors for Quality Program began• Hosted Weekly calls on a variety of Quality-related topics• Three Statewide meetings:

• Oct 3, 2012 HEN Kick-Off• March 5,6 Quality Summit• Dec 5, Quality Collaborative

Mentors for Quality

Review of past 22 months• Partnered with state to support NHSN Training and travel

to the APIC Conference for 14 participants

• Falls Prevention Expert, Dr. Pat Quigley, visited 13 hospitals/LTC

• Lean Training, funded by FLEX, provided to 5 member hospitals• Three full days of training for 3 participants from each hospital • One full day training on site for 15-20 participants at each hospital

Working Together to Prevent Falls

Data Reporting Success

• Eleven hospitals reporting on 6 or more quality topics• Falls• CLABSI• CAUTI• Pressure Ulcers• Surgical Site Infections• Early Elective Deliveries

• One hospital reporting on ALL 11 topics

Data Challenges• Different hospitals used different measure definitions

• Not everyone began at the same time

• HRET defines the first data point as “baseline” when there is not more than 12 data points(months)

• Data is not validated

• Small numbers

LET’S RUN THE NUMBERS

Baseline

May-12

Sep-12

Feb-13

Sep-13

0

2

4

6

8

10

12

14

Combined Rate of Elective

Deliveries between

37-38 Weeks

Gestation

Reducing Early Elective DeliveriesSuccess to last a lifetime

Participating Hospitals: ANMC, Bartlett, Fairbanks Memorial, Mt. Edgecumbe, PeaceHealth, South Peninsula, Sitka Community Hospital and Yukon-Kuskokwim Health Center

6+ Months Since the Last EED!

Combined Alaska Percentage

Preventing Pressure UlcersStage 1 or Higher

Participating Hospitals: Cordova, Maniilaq, Sitka, Yukon-Kuskokwim

1968 Discharges from 4 hospitals = 1 patient discharge= 1 patient with an ulcer

Baseline

Jan-12

Feb-12

Mar-12

Apr-12

May-12

Jun-12

Jul-12

Aug-12

Sep-12

Oct-12

Nov-12

Dec-12

Jan-13

Feb-13

Mar-13

Apr-13

May-13

Jun-13

Jul-13

Aug-13

Sep-13

0

0.5

1

1.5

2

2.5

3

Preventing CLABSIAll Tracked Units, by Device Days

Rate/1000 Device Days

Participating Hospitals: ANMC, Bartlett, Central Peninsula, Fairbanks, Memorial, Mt. Edgecumbe, PeaceHealth, South Peninsula

Alaska Rate

HEN Rate

3 Hospitals had no CLABSIs!

4 AK Hospitals’ Average Performance

Outpaced the HEN’sAverage

Rate of CLABSI

Alaskan Hospitals

HEN

0.0

0.5

1.0

1.5

2.0

2.5

3.0

2.4

1.9

1.1 0.9

0.30 0 0

Preventing CLABSIRate / 1000 Discharges

Participating Hospitals: Cordova, Maniilaq, Sitka, Petersburg, Yukon-Kuskokwim

1161 Discharges from 5 hospitals – No CLABSI = 1 patient discharge

Participating Hospitals: ANMC, Bartlett, Central Peninsula, Fairbanks Memorial, Mt. Edgecumbe, PeaceHealth, South Peninsula

02468

10121416 15

8.4

3.72.4 1.9 1.4

0 0

Preventing CAUTIAll Tracked Units, by Catheter Days

Alaska Rate

Rate per 1000 Urinary

Catheter Days

HEN Rate

2 AK Hospitals’ Average Performance

Outpaced the HEN’s Average Rate of CAUTI

Alaskan Hospitals

HEN

Basel

ineJan

-12Feb

-12Mar-

12Ap

r-12May

-12Jun

-12Jul-12Au

g-12Sep

-12Oct-

12Nov

-12Dec-

12Jan

-13Feb

-13Mar-

13Ap

r-13May

-13Jun

-13Jul-13Au

g-13Sep

-130.00

4.00

8.00

12.00

2 Hospitals had no CAUTI!

Falls and Injury PreventionFalls By Discharges

Cumulative Rate of Falls

Participating Hospitals: Cordova, Maniilaq, Petersburg, Sitka, Yukon-Kuskokwim

Dec-12 Mar-13 Jun-13 Sep-130

2

4

6

8

Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-130

0.05

0.1

0.15

0.2

0.25

0.3

0.35

Alaska Rate

Individual Hospital Rates

Absolute Values of Falls for All Hospitals

Falls and Injury PreventionRate of Falls, With or Without Injury

Rate/ 1000 Patient Days

Participating Hospitals: ANMC, Central Peninsula, Fairbanks Memorial, PeaceHealth, South Peninsula

2011

Jan-12

Feb-12

Mar-12

Apr-12

May-12

Jun-12

Jul-12

Aug-12

Sep-12

Oct-12

Nov-12

Dec-12

Jan-13

Feb-13

Mar-13

Apr-13

May-13

Jun-13

Jul-13

Aug-13

Sep-13

Oct-13

0

1

2

3

4

5

6

7

Alaska Rate and trend line

HEN Rate

2011Jan

-12Feb

-12Mar-

12Ap

r-12May

-12Jun

-12Jul-12Au

g-12Sep

-12Oct-

12Nov

-12Dec-

12Jan

-13Feb

-13Mar-

13Ap

r-13May

-13Jun

-13Jul-13Au

g-13Sep

-13Oct-

130.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

10.0

AK RateUCL+2 sigma+1 sigmaAverage-1 sigma-2 sigmaLCL

Falls and Injury PreventionRate of Falls, With or Without Injury

Rate/ 1000 Patient Days

Participating Hospitals: ANMC, Central Peninsula, Fairbanks Memorial, PeaceHealth, South Peninsula

THE RESULTS ARE A CALL TO ACTION!

Looking Ahead:• Increased quality reporting demands

• Increased consumer pressure for quality transparency

• Increased government “involvement” in quality /transparency/payment/clinical practice

• Increased Payor push for payment reform

ASHNHA Quality Strategy

Offensive or Defensive?

Who’s got the ball?

ASHNHAQuality Strategy

Data• ASHNHA members walk the talk of Quality Transparency• ASHNHA members have control over data• ASHNHA members have collective ability to respond to

public, state• ASHNHA members have ability to benchmark against

state and national benchmarks• Relatively non-competitive market allows a “raise all

boats” mentality

2014

ASHNHA Qualityan invitation to all members

ASHNHA Partnership for Patients(PfP)Statewide QI Effort Guided by Nat’l PfP effort Statewide direction by PfP Advisory Group Reporting Data to ASHNHA on 10 TopicsTo focus on streamlining data collection

Future ASHNHA ResponseHospitals--working together to improve care in Alaska!