MHA: Strategic QualitysUpWednesday... · August 13 MBQIP – Review of Emergency Department...
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MHA: Strategic Quality What’s Up Wednesday|Lunch and Learn Your clinical quality, process improvement resource Jessica Rowden, RN, BSN, MHA Clinical Quality Improvement Manager http://web.mhanet.com/strategic-quality/ 1
Transcript of MHA: Strategic QualitysUpWednesday... · August 13 MBQIP – Review of Emergency Department...
MHA: Strategic Quality What’s Up Wednesday|Lunch and Learn Your clinical quality, process improvement resource
Jessica Rowden, RN, BSN, MHA
Clinical Quality Improvement Manager
http://web.mhanet.com/strategic-quality/
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Housekeeping
Interactive networking platform
Press *1
Type questions in the question box feature of the webinar platform
Please fill out the evaluation
Give feedback
Offer suggestions of what would be beneficial to your organization
Be a featured hospital speaker!
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August Topics of Interest
Patient and family engagement
Hourly Rounding
Pain Management
SSI reduction process – Cox Monett
MHA Update
Transparency update
HEN 2.0 update
Immersion project update
Recognition opportunities
Upcoming events 3
Refresher – Data
HIDI: www.hidianalyticadvantage.com
Quality Collections is a data portal warehouse
HIDI Analytic Advantage® reports available under the “Quality” tab
Touch base with me if you have questions
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Patient and Family Engagement Quality Resource Briefs
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Patient and Family Engagement: Hourly Patient Rounding Why hourly round?
It is part of an exceptional care model
Bridge communication between patients, families, care providers
When patients’ families are actively involved in rounds, hospitals observe fewer falls and readmissions
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Click here to see different ways to engage patients
and families in hourly rounding and more
hourly rounding resources!!
Patient and Family Engagement: Pain Management
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Click here to see the full pain management brief
Inherent Suffering
Avoidable Suffering
Barriers to effective
pain management
Patient and Family Engagement: Pain Management
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Strategies for Providers Organizational Strategies
Set patient expectations appropriately Initiate a pain-control policy that integrates the patient’s perspective
Anticipate the pain medication schedule Review the process for pain medication delivery from the pharmacy to the nursing unit
Stay in constant communication with patients while trying to control their pain
Educate all front-line providers about pain assessment and management expectations
Understand that pain in emotional and physical
Become familiar with nonmedication pain control options to provide patients with “high touch” options
Record current pain levels on a whiteboard
Educate patient about how to manage their pain after being discharged
Hospital Spotlight
Cox Monett
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MRSA Surgical Site Infections
Following Cesarean Section
Cox Monett Hospital
• 25 bed Critical Access Hospital
• CoxHealth System
• Located in southwest Missouri serving the four state region: MO, AR, KS, OK
• 18 acute/observation Medical Surgical Beds
• 7 Labor and Delivery Beds
• Swingbed, Respite, Multiple OP Services
• DNV Accreditation
Why Deliver Your Baby at Cox Monett?
• July 2001 New Labor and Delivery Unit
• One of two CAH in rural area that delivers babies. Nearest acute care facility is 43 miles.
• Currently 3 local physicians who deliver.
• Average annual number deliveries for the last three years - 289.
• Average annual number of cesarean sections over the past three years: 68 and declining.
NHSN SSI Definition
• Superficial Incisional
Primary
Secondary
• Deep Incisional
Primary
Secondary
• Organ Space
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Trend analysis showing the rate of C-Section infections reported in 2012 and 2013 - Cox Monett Hospital - Rate per 100 cases.
2012 2013
Baseline data
MRSA
Methicillin-resistant Staphylococcus aureus
–Gram Positive Cocci
– Surveillance: Colonization vs Infection
–Mode of Transmission
1. Healthcare Worker Hands
2. Shared Patient Care Items
3. Environment
• MRSA infections can be prevented
Family and Community Impact
• Prolonged Healing
• Readmission
• Bonding and Breastfeeding
• Small Community-News Travels Fast!
• Fear of Infection
Interventions
• Team Approach
• Hand Hygiene
• Patient and Family Involvement
• Environmental Services
• Skin Prep
• Post-op and Discharge Wound Education
Hand Hygiene
• Lack of proper hand hygiene is one of the leading causes of HAIs.
• Mandatory Education
• Monitor technique as well as action
• Hand Hygiene Audits
• Additional Hand Hygiene Dispensers
Family and Patient Involvement
Environmental Services
• Designation of who cleans what
• Design of EVS checklist for standardization • http://www.cdc.gov/HAI/toolkits/Environmental-Cleaning-Checklist
• Validation of new process
• Education
• Review of products
Skin Prep
• Preoperative teaching for scheduled sections
• CHG soap provided for shower the night before and the morning of section.
• CHG wipes
• CHG operative skin prep has 3 minute dry time.
Wound Education
• May shower daily. Keep incision clean and dry between showering.
• Do not vigorously scrub over incision.
• Do not cover incision.
• Do not pick at incision.
• Do not apply any medication unless directed to do so by physician.
• When to call physician.
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# of Sections
# of Infections
Congratulations! • Leadership
Recognition
• Verbal
• Monthly Feedback
• Pizza Party!
• PIX
Contact Information
Denise Staponski, RN Infection Prevention 417-354-1434
Bev Eli, BSN Chief Nursing Officer 417-354-1410
Heather Hood, RN Nurse Manager Special Delivery Unit 417-354-1411
Questions?
MHA Update
Transparency
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Transparency Update
Continue to encourage your CEOs to sign the DUA for transparency
Data was updated in July
Price and quality transparency FAQ sheet was distributed in July
September 25, from 2 - 3 p.m. - MHA's Price and Quality Outcome Transparency Initiative (register, then dial 866/450-8659, Conf. ID# 76012181)
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MHA Update
HEN 2.0
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CMS
AHA/HRET
MHA
Center for Patient Safety
~90 hospitals
~30 other State Hospital Associations
~30 other National HENs
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MHA is part of AHA/HRET’s HEN cohort
Visit the HEN tab on our website for HEN updates
HEN 2.0 Timeline
March 23
• MHA submit final preliminary budget to HRET
March 28
• HRET submit RFP to CMS
August
• CMS to award grant
• Formal letters of commitment will be sent to MO hospital CEOs
Mid-September
• Projected starting period of HEN 2.0
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Optional/additional topics Severe Sepsis and Septic Shock
Hospital Culture of Safety that fully integrates patient safety with worker safety
Iatrogenic Delirium
C. diff including antibiotic stewardship
Undue Exposure to Radiation
Airway Safety
Failure to Rescue
HEN 2.0 Overview
10 core topics (all applicable topics are required) Adverse Drug Events
CAUTI
CLABSI
Injuries from falls and immobility
OB adverse events
Pressure Ulcers
SSI
VTE
VAE
Readmissions
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HEN update
Focus on “doing” work, not “planning”
Role-based care
Continue the Improvement Leader Fellowship structure
New national resources
Updated HRET website
HEN YouTube page
Recruitment period will be time sensitive (~2 weeks)
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Potential HEN Data Measures
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Topic Measure(s)
CAUTI • Standardized Infection Ratios 1 2 3: CDC NHSN (NQF 0138) • Catheter utilization: CDC NHSN
CLABSI • Standardized Infection Ratios 1 2 3 : CDC NHSN (NQF 0139) • Central line utilization: CDC NHSN
Falls • Falls w/injury 4 (NQF 0202)
OB/EED • Early elective deliveries (PC-01, NQF 0469) • OB trauma – vaginal delivery w/ instrument (AHRQ PSI 18) • OB trauma – vaginal delivery w/out instrument (AHRQ PSI 19)
Pressure ulcers • Pressure ulcer stage 3+ (AHRQ PSI 03) • Pressure ulcer stage 2+ (NQF 0201)
Surgical site infections
• Standardized Infection Ratios 1 2 5: ACS-CDC (NQF 0753) Colon surgery, abdominal hysterectomy, total hip replacements, total knee replacements
Venous thromboembolism
• Post-operative pulmonary embolism or DVT (AHRQ PSI 12)
Ventilator associated events
• Ventilator-associated complication (VAC) rate CDC NHSN 1 2 • Infection-related ventilator-associated complication (IVAC) rate CDC NHSN 1 2
Adverse Drug Events
• All adverse drug events Focus on opioid safety, anticoagulation safety and glycemic management
Readmissions • All cause 30 day readmissions
1 Hospitals using NHSN may confer rights to MHA/HIDI 2 For hospitals not reporting to NHSN, hospital submitted infection rates will be used 3 All inpatient locations except NICU 4 All acute care units 5 Hospitals should report on all surgeries
Pending CMS Feedback:
• Additional outcome measures
• Process measures • Baseline
measurement timeframe
NHSN Data
Confer your NHSN rights.
Why?
To provide you the most robust data portfolio
To better assist you with more improvement opportunities
See the Instructional Guide
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Decrease the amount of time spent submitting data!
HEN Data Webinars
Series of data webinars are being scheduled August through September
Caveat: we are available to do one-on-one webinars
Showcase Quality Collections data capabilities
Review Analytic Advantage® reports
Registration for webinars is forthcoming on the website
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Additional Data Support
Quality Collections User Guide
1:1 support
Excel templates for data collection and submission
Standard reports pushed to executives
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HEN 2.0 Hospital Expectations to Ensure Success
Participate in webinars and in-person meetings and utilize the tools and resources available to them to drive improvement in all target areas
Form a HEN team or add HEN to an existing quality meeting agenda
How will you do this? Who will be on your team?
Schedule monthly meetings!
Who is going to be in charge of data?
– Ensure they have access and are fluent with HIDI Quality Collections and Analytic Advantage
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MHA Update
Immersion Projects
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Immersion Project
Rapid-process improvement model
Data submission
Quarterly guided participant calls
Quarterly guided deliverables
Ability to network across group participants
End-of-project report out
TOPICS
• Falls • Readmission
• CAUTI • OB
• Sepsis – ED/EMS
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September Recruit for Immersion
Projects (IP)
October 15 In-person meeting
December/January IP Huddle webinar
March/April IP Huddle webinar
June IP Huddle webinar
July/August End of project in-person meeting
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Imm
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Pro
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Tim
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Recognition Opportunities
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Missouri Association for Healthcare Quality (MOAHQ)
Distinguished Quality Award
Open for nominations
– Anyone can nominate, but nominee must be a MOAHQ member
– Visit http://www.moahq.org/dqpaward.php for nomination form
– Due August 14th
If you are not a MOAHQ member, please consider joining
– Visit http://www.moahq.org/ for more information
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National: Quest for Quality Award
Nomination form www.aha.org/questforquality – due October 11, 2015
Prize honors are
One winner; up to two finalists; and up to four Citations of Merit honorees.
The winner will receive $75,000; each finalist will receive $12,500. The awards will be presented at the AHA-Health Forum Leadership Summit (July 17-19, 2016) in San Diego.
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Member Resources and Support
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http://web.mhanet.com/strategic-quality/ 48
Website Resources
Missouri Quality Snapshot – Quarterly
Past webinar recordings and presentations
MHA Resources
guides, IPPS updates, toolkits, Quality Resource Briefs, OB
AHRQ and IHI toolkits and guides
Upcoming event registration
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Seven Things to Start Next Week (or the week after): Action Items
Systematically distribute PFE Quality Resource Briefs to frontline staff and encourage their engagement
Start hardwiring hourly patient rounding at your hospital
Schedule some time with your CEO
Discuss signing your DUA for transparency
Discuss upcoming HEN and quick turnaround time for recruitment
Confer NHSN rights with HIDI
Nominate a Distinguished Quality Professional
Nominate/apply for Quest for Quality Award
Visit MHA SQI website and sign up for upcoming events
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Upcoming Events
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Upcoming Events – Strategic Quality
August 13 MBQIP – Review of Emergency Department Transfer Communication EDTC Measures and data collection – 11AM-12PM
August 19 – HEN Kickoff Webinar (registration coming soon)
September 2, from Noon to 1 p.m. - Lunch & Learn: What's Up Wednesday (register, then dial 855/427-9512, Conf. ID# 30785783)
Fall Regional Meetings – Clinical Excellence and Harm Reduction
September 16, Marriott West, 660 Maryville Centre Dr., St. Louis (Register)
September 17, Ste. Genevieve County Community Center, 21390 MO-32, Ste. Genevieve, Mo. (Register)
September 22, Courtyard KC/Blue Springs, 1500 NE Coronado Dr., Blue Springs, Mo. (Register)
September 24, Hilton Garden Inn, 4155 South Nature Center Way, Springfield, Mo. (Register)
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September 25, from 2 - 3 p.m. - MHA's Price and Quality Outcome Transparency Initiative (register, then dial 866/450-8659, Conf. ID# 76012181)
October 7, from Noon to 1 p.m. - Lunch & Learn: What's Up Wednesday (register, then dial 855/427-9512, Conf. ID# 30785784)
October 15 – HEN 2.0 kickoff in-person meeting
Hilton Garden Inn, Columbia, MO
Registration coming soon
MBQIP Fall Regional Meetings – Dates and locations coming soon
Emergency Preparedness:
On-demand education to assist hospital staff with preparing their organizations for civil unrest events will be made available on our website in mid-August. Hospital security directors and emergency preparedness staff will be notified when the resources are posted. Jackie Gatz
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Upcoming Events – Strategic Quality
MHA:SQI – http://web.mhanet.com/strategic-quality/
Leslie Porth, Ph.D., R.N.,
MSN
Senior Vice President of
Strategic Quality Department
Triple Aim
Population Health
Oversight of division (Quality Improvement, Quality Works,
Emergency Preparedness)
MONL
Alison Williams, R.N., BSN, MBA-
HCM
Vice President of Clinical Quality Improvement
Dana Downing,
B.S., MBA-H, CPHQ
Vice President of Quality Program
Development
National quality measures
Quality outcome transparency
Electronic clinical quality measures
FLEX grant
MOAHQ facilitation
Stephen Njenga, MPH, MHA, CPHQ
Director of Performance
Measure Compliance
MBQIP
Data Management and analytics
HEN projects
Performance measurement
Quality Works grant projects, education
MOAHQ
Jessica Rowden, R.N.,
BSN, MHA
Clinical Quality Improvement
Manager
Clinical quality SME
Data management and analytics
HEN/AHRQ grant projects
TeamSTEPPS master trainer
Host of WUW|LNL
MOAHQ
MONL
Social Media
Cheryl Eads
Executive Assistant of
Quality Improvement
Provides support to the SQI team
Coordinates webinars,
conference calls and meetings
Distributes correspondence and
communication
Assists in maintaining reports
[email protected] 573/893-3700x1305
[email protected] 573/893-3700x1326
[email protected] 573/893-3700x1314
[email protected] 573/893-3700x1391
[email protected] 573/893-3700x1382
Clinical quality SME
Oversight of Quality Improvement
Grant management
Collaborative management
Patient & Family Engagement
MONL
MOAHQ
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[email protected] 573/893-3700x1325
Thank You for Joining Us
Please fill out the evaluation
Give feedback and offer suggestions
Debrief: tell us what went well and what didn’t
What topics would be beneficial to your organization
Be a featured hospital speaker at regional meetings or WUW 2016
See you next month September 2 at noon
Patient & family engagement in transitions
Southeast Hospital – stroke program and reducing door to needle time
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