1. Title Block Data Office Hours January 2014 Dolores Hagan, RN, BSN K-HEN Education/Data Manager Debbie Campbell, RN-BC, MSN CCRN K-HEN Improvement Advisor

2. Agenda Review of participation levels and requirements Discuss measure specifications Examine appropriate sampling techniques Demonstrate data collection tool Harm Across the Board Template

3. Commitment Letter Background – CMS statement of work (SOW) –Continue the 40/20 reduction of harm goal –Ten focus areas with specific areas of focus defined –Includes Patient and family engagement (PFE) Leadership Healthcare disparities Teamwork and communication Measurement

4. Participation Levels CMS scoring—HEN, State and Hospital level –Participation level –Improvement level –LOP (Z – 5) K-HEN Participation requirements defined by the CMS scoring document –Minimum level yields minimum score –Full level yields maximum score

5. K-HEN Incentive Plan K-HEN defined Not all states in the HRET HEN are doing this Structured around –the level of participation –Timeliness of data submission

6. Data Submission Schedule Period Recommended Data Submission Schedule (All except Readmissions & SSI) Jan 2014Mar 1, 2014 Feb 2014Apr 1, 2014 Mar 2014May 1, 2014 Apr 2014Jun 1, 2014 May 2014Jul 1, 2014 Jun 2014Aug 1, 2014 Jul 2014Sep 1, 2014 Aug 2014Oct 1, 2014 Sep 2014Nov 1, 2014 Oct 2014Dec 1, 2014 Nov 2014Jan 1, 2015 Dec 2014Feb 1, 2015 Period Recommended Data Submission Schedule Jan 2014Apr 1, 2014 Feb 2014May 1, 2014 Mar 2014Jun 1, 2014 Apr 2014Jul 1, 2014 May 2014Aug 1, 2014 Jun 2014Sep 1, 2014 Jul 2014Oct 1, 2014 Aug 2014Nov 1, 2014 Sep 2014Dec 1, 2014 Oct 2014Jan 1, 2015 Nov 2014Feb 1, 2015 Dec 2014Mar 1, 2015

7. Measures by Area Adverse Event Area (AEA) Measures Adverse Drug Events (ADE) Excessive anticoagulation (EOM-12) Glucose control (EOM-13) Opioid safety (EOM-111) An overall measure of ADEs (EOM-112) FallsFalls with or without Injury (EOM-37) Falls with injury (minor or greater) (EOM-38) Pressure UlcerStage II or Greater hospital acquired (EOM-58) Stage III or IV greater subset (AHRQ PSI 3) (EOM-61) VTEPost-op PE or DVT (AHRQ PSI 12) (EOM-105) Potentially preventable VTE (EOM-104) EEDEarly Elective Delivery (JC PC-01) (EOM-40)

8. Measures by Area AEA Measures Other OBBirth Trauma Rate – Injury to Neonate (AHRQ PSI 17) (EOM- 48) OB Trauma rate-vaginal delivery with instrument (AHRQ 18) (EOM-54) Birth Trauma Rate-vaginal delivery without instrument (AHRQ 19) (EOM-55) OB Hemorrhage (EOM-118) Preeclampsia treatment and management to prevent morbidity and mortality (EOM-120) Readmissions Diagnosis specific 30-Day readmission rate AMI (EOM-76); Heart Failure (EOM-77); Pneumonia (EOM-78) 30-Day All Cause readmission rate (EOM-75)

9. Measures By Area AEAMeasures CAUTI CAUTI Rate (NHSN/NDNQI) – ICU only (EOM-19) CAUTI Rate (NHSN/NDNQI) – All Units (EOM-18) Catheter utilization ratio (catheter days/patient days) (EOM-21d) ED Catheterization rate* CLABSICLABSI rate (NHSN/NDNQI) ICU only (EOM-25) CLABSI rate (NHSN/NDNQI) All Units (EOM-24) Days Since Last CLABSI* SSISurgical site infection rate (NHSN) for colon and abdominal hysterectomy procedures within 30 days of procedure(EOM-89) Surgical site infection rate (NHSN) for four or more procedures within 30 days of procedure** VAE/VAPVAC (NHSN) (EOM-96a or EOM-96d) IVAC (NHSN) (EOM-96b or EOM-96e) Possible/Probable VAP (NHSN) (EOM-96c or EOM-96f)

10. Measure Specifications Most measures are nationally recognized standard measures –Follow the national specifications –May sample if the specification allows for it Non-standard measures –State-wide specifications are under development –ADE Excessive Anticoagulation example

11. Auditing Basics Deborah R. Campbell, RN-BC, MSN, CCRN Alumna K-HEN Quality Improvement Advisor Kentucky Hospital Association

12. –A sample is: A few of many Part of a whole –A good sample is something else! Sampling

13. Common Errors: –Too small –Not representative Representative samples allow us to make accurate statements about our population as a whole Obtaining a meaningful sample

14. –IDEALLY, we would gather data on every instance of the intervention or outcome we are auditing Example: Med Rec- 100% chart review- look at every patients admission paperwork –Barriers Very large numbers Limited resources Obtaining a meaningful sample

15. –To be statistically relevant as a sample, it is accepted practice to gather at least 20 points of data monthly. If the total population you are studying or measuring is < 20/month, each and every item should be audited. If the population is larger, sampling techniques are appropriate. Obtaining a meaningful sample

16.  Avoiding Selection Bias  For items which are consecutive, use the auditing method of “Every “n”th item”.  Using the example of Med Rec again, one could design the process to audit every 10 th admission (assuming there are enough admissions per month (>200) to provide 20 total audits for the month. If there are fewer than that, one could audit every 5th admission, etc. How to gather a GOOD sample

17. Avoiding Selection bias –For measure which require counts or observations, use the scheduling of days/times per month method. Using for example CAUTI bundle compliance, one could design the process to audit: –All patients with a CVL every Monday, Wednesday and Friday. ( or Q Monday ) Things to consider: differences among days of the week relative to census, staff, types of patients. Now what??? Cont’d

18. Rotating audit schedule- more complicated, but may give you better information –Example 1 Weeks 1 and 3: M, W, F Weeks 2 and 4: Saturday and Sunday –Example 2 Weeks1 and 3: M, W, F day shift Weeks 2 and 4: M, W, F night shift (or Sat, Sun PM) –Example 3 Weeks 1 and 2: Med-Surg Units Weeks 3 and 4: ICUs Cont’d

19. Care team members other than primary RN –Supervisors, charge nurses –Nurses helping out (regular, floated, agency) –PCAs –Ward clerks –X-ray technicians –Respiratory therapists –Transporters –Family members –Patients themselves Maintenance Takes a Village

20. PLEASE let us help if this is new for you or you would just like a second opinion or advice from someone outside your everyday work flow!! Deb Campbell dcampbell@kyha.com 502-992-4383 Questions?

21. Data Collection Tool Excel spreadsheet customized to your hospital Numerators/Denominators Process measures

22. Harm Across the Board New HAB template NOT mandatory—but earns an extra incentive K-HEN will help prepare as much as possible New Improvement Calculator from HRET

23. Open Discussion/Questions Complete Learning Activity Survey