1. Tennessee Center for Patient Safety

2. Center Staff Chris Clarke, Sr. VP, Clinical and Professional Practices Patrice Mayo, VP, Operations Director Darlene Swart, VP, Clinical Director Jackie Moreland, Clinical Quality Improvement Specialist Bill Cecil, Economic and Quality Data Analyst Rhonda Clark, Quality Improvement Specialist Renee Stump, Quality Improvement Specialist Jessy Richter, Data Manager Amanda Chumley, Executive Assistant, PSO and TSQC Taelor Barnette, Executive Assistant, TCPS 2

3. Which best describes your position? A.Senior Level Management B.Manager or mid-level manager C.Frontline Caregiver D.Other 30

4. What is your professional background? A.Physician B.Nurse C.Pharmacist D.Allied Health provider E.Non-clinical professional

5. How many years have you been in healthcare? A.Less than 3 years B.3-7 years C.7-10 years D.10-20 years E.Over 20 years F.Way too long

6. Tennessee Center For Patient Safety THA Board Strategic Aim: Zero Preventable Harm 6

7. TCPS Programs Collaboratives on Healthcare-Associated Infections TN Surgical Quality Collaborative Patient Safety Organization (PSO) CMS Hospital Engagement Network TDH Breastfeeding Grant 7

8. Tennessee Center for Patient Safety 2014 Initiatives Expand healthcare-associated infections topics –Mirror state and federal reporting requirements –Expand CLABSI and CAUTI reporting outside ICU Address Partnership for Patients goals to reduce hospital-acquired conditions and readmissions Align data collection and improvement initiatives with other state agencies and key stakeholders including the Tennessee Department of Health, Qsource, Tennessee Initiative for Perinatal Quality Care (TIPQC), professional organizations, and CMO Society 8

9. Collaboration and Partnership

11. AHRQ Hospital Survey on Patient Safety Culture IHI Open School for Health Professions TCPS Weekly Newsletter TCPS website http://www.tnpatientsafety.com http://www.tnpatientsafety.com TCPS Report Distributor –Data feedback and comparisons TCPS Resources for Hospitals

12. THA Transparency Timeline Dec 2009January 2010April 2010July 2010April 2011July 2011Dec 2011April 2012 THA Board Aim Zero Preventable Harm CEO monthly scorecards CMO Society Recommendation to un-blind data Board approval Public Website for Quality TN Dept. of Health 1st Public Report on CLABSI THA Board Blinded Site Comparison reports THA Board Site Specific reports

13. Federal Reporting CMS programs

14. IQR HAC HRRP Alphabet Soup of Reporting OQR VBP MU IQR

15. What does IQR stand for? A.Institutional Quality Records B.Inpatient Quality Reporting C.Incredibly Quirky Rules D.I have no clue

16. What does HAC mean? A.Hospital Air Conditioning B.Healthcare audits and compliance C.Hospital-Acquired Condition D.Unauthorized access to computer information

17. Which of the following programs apply to hospitals in FY 2015? A.Value-Based Purchasing B.Hospital-Acquired Conditions Penalty C.Readmissions Penalty D.All of the above

18. In what month does the fiscal year begin for federal programs? A.January B.July C.October D.March E.December

19. IQ R Hospital Acquired Condition Hospital Readmission Reduction Penalty Alphabet Soup of Reporting Outpatient Quality Reporting Value Based Purchasing Meaningful Use Inpatient Quality Reporting

20. Inpatient Quality Reporting Significant measure changes for FY 2017 CMS removal of “topped out” chart-abstracted measures Expands voluntary electronic clinical quality measure (eCQM) reporting option Credit for both IQR and EHR Incentive Program Retains the eCQM version of 10 removed measures Adds 6 measures that are only reportable as eMeasures

21. IQR Comings and Goings Measures for Permanent Removal –Cardiac surgery data participation –4 SCIP measures –4 previously suspended measures New measures for FY 2017 –CABG readmissions –CABG mortality –Pneumonia Payments per 30-day episode of care –Heart Failure Payments per 30-day episode of care –Severe Sepsis and Septic Shock Bundle (NQF #500)

22. Value-Based Purchasing In FY 2015, funded by reducing base operating payments by 1.5 percent −Budget neutral (all funds paid to hospitals) −Available pool of FY 2015 VBP Funds: $1.4 billion FY 2017 New Measures MRSA C Difficile Early Elective Delivery FY 2019 New Measure Total Hip and Total Knee Arthroplasty Complications

23. VBP Domain Weight Changes For FY 2017, CMS removes six topped out process measures CMS places significantly less weight on process measures Measure Domain FY 2017 Weight Adopted in FY 2014 IPPS Final Rule Proposed FY 2017 Weight Safety15%20% Clinical Care:  Clinical Care – Outcomes  Clinical Care – Process 35%  25%  10% 30%  25%  5% Efficiency and Cost Reduction25% Patient and Caregiver Centered Experience of Care / Care Coordination 25%

24. Hospital-Acquired Conditions FY 2015 is first year for HAC Penalties –1 percent reduction to total Medicare payments for hospitals in top quartile of national HAC rates Measures finalized in last year’s IPPS final rule Domain 1: Patient Safety Indicators (PSI 90) Composite Domain 2: Infection measures CAUTI, CLABSI CMS calculates “Total HAC Score” for each hospital using formula below: 9 35% x (Domain 1 Score) + 65% x (Domain 2 Score)

25. Hospital-Acquired Conditions Domain 1 PSI 90 includes: –PSI 3 Pressure Ulcer Rate –PSI 6 Iatrogenic pneumothorax rate –PSI 7 CLABSI rate –PSI 8 Post-op hip fracture rate –PSI 12 Post-op PE/DVT rate –PSI 13 Post-op sepsis rate –PSI 14 Wound dehiscence rate –PSI 15 Accidental puncture/laceration rate

26. HAC Estimated Impact – FY 2015 Penalties for 726 hospitals −22% of eligible hospitals −Reduces hospital payments by $369 million Most impacted? −Penalizes over 50% of major teaching hospitals −Penalizes over 40% of hospitals with 500+ beds HAC Penalty scores will be posted on Hospital Compare December 2014 9

27. HAC Program Changes FY 2016 “Total HAC Score” weights HAIs more heavily: 25% x (Domain 1 Score) + 75% x (Domain 2 Score) FY 2016 - Adds SSI FY 2017 - Adds C-diff and MRSA CMS interested in all-cause harm measure derived from EHRs 9

28. Readmissions 1 in 7 Medicare patients experiences an adverse event while in the hospital 1 in 5 Medicare patients are readmitted within 30 days of discharge

29. Readmissions Penalty Program Began in FY 2013 –Reduced payments for IPPS hospitals with higher than expected readmission rates ( 1% reduction) – Payments decreased for all Medicare patients – Based on current CMS 30 day readmission rates for AMI, heart failure, pneumonia – $8.5 million dollars in TN penalty with 49% of hospitals having some penalty FY 2014 – penalty increases to 2% FY 2015 – 3% penalty

30. Hospital Readmissions Reduction Program FY 2015 changes –Penalty increases to 3% (per statute) –Addition of COPD and total hip/total knee arthroplasty measures –Updates to planned readmission algorithm – Penalties: $424 million FY 2017 –Addition of readmissions following CABG Detailed information and FAQ’s on all reporting programs Available on the QualityNet website, www.qualitynet.org

31. Progress

34. Infections and complications reductions – 3,592 fewer adverse events –$23,472,618 estimated cost savings Readmissions reduction –15,720 fewer readmissions –$150,912,000 estimated cost savings Total savings = $174,384,618 and 19,312 events/readmissions Annualized Estimated Impact

35. How can THA best support your leadership in improving quality and safety? A.Engage Senior Leaders and Trustees B.Provide national experts and resources C.Share innovations and best practices D.Provide peer-to-peer mentoring

36. THA Leadership Summit –November 5th, in conjunction with THA annual meeting November 5-7 –Call for presentation and poster abstracts Deadline: August 22nd Tennessee Center for Patient Safety