1. Pressure Ulcer K-HEN Data Collection & Submission Dolores Hagan, RN BSN K-HEN Education and Data Manager August 2012

2. Objectives Review reporting requirements Review K-HEN recommended measures Review the specifications for monitoring data (Inclusion and exclusion criteria) Discuss requirements for baseline data Define data entry and submission timeline Identify measures that may be pulled from other systems where data is currently being entered 2

3. Reporting Requirements For each topic area chosen, hospitals are required to submit data for at least – One process measure AND – One outcome measure Hospitals are strongly encouraged to report on the K-HEN recommended measures Additional outcome and/or process measures may be selected and reported as desired 3

4. K-HEN Recommended Measures Purpose—standardize reporting on the same measures across the state for robust benchmarking capability Measures selected based on polling data from the KHA Quality Conference in March 2012 Have continued to evolve with your feedback (Keep it coming! ) 4

5. HRET HEN Encyclopedia of Measures Lists all measures available in the CDS Defines the numerator and denominator for each measure Provides a link to the source of the measure http://www.k- hen.com/Portals/16/Documents/HRET_HEN_ Encyclopedia_of_MeasuresV3.pdf http://www.k- hen.com/Portals/16/Documents/HRET_HEN_ Encyclopedia_of_MeasuresV3.pdf 5

6. Pressure Ulcer Prevention: Outcome Measure Preferred measures: Depends on your patient population) – # 61 Adult patients with Stage III, Stage IV or unstageable pressure ulcers (AHRQ PSI 3) – #62 Pediatric patient with a decubitus ulcer (AHRQ PDI 2) – #63 Number of occurrences of hospital acquired pressure ulcer at Stage III or IV 6

7. Numerator--Discharges among cases meeting the inclusion and exclusion rules for the denominator with ICD-9-CM code of pressure ulcer in any secondary diagnosis field and ICD-9-CM code of pressure ulcer stage III or IV (or unstageable). ICD- 9-CM Pressure ulcer diagnosis codes Codes are listed in the – Encyclopedia of Measures – http://www.qualityindicators.ahrq.gov/Downloads/Soft ware/SAS/V43/TechnicalSpecifications/PSI%2003%20Pr essure%20Ulcer%20Rate.pdf http://www.qualityindicators.ahrq.gov/Downloads/Soft ware/SAS/V43/TechnicalSpecifications/PSI%2003%20Pr essure%20Ulcer%20Rate.pdf 7 #61 Pressure Ulcer Outcome Criteria Source: AHRQ Patient Safety Indicators

8. #61 Pressure Ulcer Outcome Criteria Denominator—All medical and surgical discharges age 18 years and older defined by specific DRGs or MS-DRGS (See Patient Safety Indicator Appendices) Exclusions – LOS < 5 days – Principal or secondary diagnosis of pressure ulcer present on admission – MDC 9 (skin, subq tissue and breast) – MDC 14 (pregnancy, childbirth and puerperium) – Any diagnosis of hemi, para or quadraplegia – ICD-9 procedure code for debridement or pedicle graft before or on the same day as the major OR procedure 8 Source: AHRQ Patient Safety Indicators

9. Exclusions Continued – Transfer from a hospital (different facility) – Transfer from a Skilled Nursing Facility or Intermediate care facility – Transfer from another health care facility 9

10. # 63 Pressure Ulcer Outcome Criteria Numerator—Number of occurrences with Pressure ulcer stages III or IV (ICD-9 Codes: 707.23(MCC) or 707.24(MCC)) as a secondary diagnosis with a POA code of ‘N’ or ‘U’ Denominator—Number of acute inpatient FFS discharges Exlcusions: – Swing bed patients 10

11. Pressure Ulcer Process Measure Preferred Measure: #57 Patients with skin assessment documented within 24 hours of admission 11

12. #57 Pressure Ulcer Process Criteria Numerator—Inpatients with timely, complete skin assessment – Skin temp, color, moisture, turgor, integrity Denominator—All inpatients admitted to hospital or unit under surveillance 12 Source AHRQ Pressure Ulcer Toolkit

13. Baseline Data Only submitted one time For all topic areas except Readmissions: – Baseline data is from 2011 prior to January 1, 2012 – May be the entire calendar year of 2011 or any other period within the year (a month, a quarter, etc) – Enter your specific period beginning and ending dates Readmission Baseline Data – Preferably CY 2011 – May use Jan – Jun 2012 if 2011 data is not available If no baseline data is available, do not enter anything for baseline—begin with monitoring data 13

14. Pressure Ulcer Data Entry Complete baseline data entry by August 31! Data should be entered on a monthly basis as much as possible 14

15. Pressure Ulcer 2012 Monthly Data Entry Schedule Monitoring MonthData Entry AvailableData Entry Complete JanuaryImmediatelyAs soon as possible* FebruaryImmediatelyAs soon as possible* MarchImmediatelyAs soon as possible* AprilImmediatelyAs soon as possible* MayImmediatelyAs soon as possible* JuneImmediatelyAs soon as possible* JulyAugust 1, 2012August 31, 2012 AugustSeptember 1, 2012September 30, 2012 SeptemberOctober 1, 2012October 31, 2012 OctoberNovember 1, 2012November 30, 2012 NovemberDecember 1, 2012December 31, 2012 DecemberJanuary 1, 2013January 31, 2013 15 *If data is available

16. Comprehensive Data System (CDS) Link to HRET training webinar for CDS located on K-HEN website under Data Page https://www.hretcds.org/Login.aspx Data coordinator receives initial login and creates hospital’s users – At least two data administrators – As many data entry users as needed 16

17. Measure Selection Review the K-HEN Recommended Measures and the HRET Encyclopedia of Measures Determine which measures you will report Remember you MUST report on at least one process and one outcome measure per topic area selected 17

18. Measure Enrollment Enroll in the measures that you are reporting Select Admin  Measure Enrollment – Select the topic area – Select/deselect and save the measures that you will be reporting on – This will narrow your choices for data entry to only those selected – You may reselect those measures at a later time if desired 18

19. Data Collection & Entry Review the numerator and denominator criteria for the measures selected Collect and compile the data Sign on to the CDS – Select Data Entry tab – Select the topic from the drop  Select Next – Find the appropriate measure  Select Enter Data 19

20. Baseline Data Entry Defaults to the Baseline tab Enter the Measurement start and end dates  Select ‘Add’ Under ‘Data Entry’ column, Select ‘Go’ Was data collected for this measurement period?  Select Yes or No – If No, enter reason (e.g. data not available) – If Yes, enter the numerator and denominator – Select Save or Submit Save holds data in ‘temporary’ area and is not available for reporting within the CDS Data may be edited by the hospital until it is submitted 20

21. Monitoring Data Entry Select the Monitoring tab Under the Data Entry column, Select ‘Go’ for the appropriate month Was data collected for this measurement period?  Select Yes or No If No, enter reason (e.g. data not available) If Yes, enter the numerator and denominator Select Save or Submit – ‘Save’ holds data in ‘temporary’ area and is available for reporting within the CDS – Data may be edited by the hospital until it is submitted 21

22. Data Tidbits Each month should have data entered or a reason it was not collected Additional training will be provided after data has been entered and reporting is available 22

23. Monthly Progress Report Due to K-HEN by the 10 th of each month Use template provided One report per topic area Report template and sample complete report located on K-HEN website (www.k- hen.com) under Tools and Resourceswww.k- hen.com 23

24. Aim?: (Including your How Good and By When statement) Why is this project important?: Aim Statement Changes being Tested, Implemented or Spread Recommendations and Next Steps Lessons Learned Run Charts (For each listed change, indicate whether it is being tested (T), Implemented (I) or Spread (S)) (Enter summary here) Enter summary here (what do you need from Executive Project Champion, Sponsor at this time to move project?) Recommendations Next steps for testing Project Title: ______________________________ Date: _____________ Hospital Name: ____________________________ State: _____________ © 2012 Institute for Healthcare Improvement Team Members (Name of Project Champion, Senior Leader Sponsor & all other names & roles) (Make fonts large, title, labels, dates and notes very simple on graphs prior to shrinking graphs. Should be able to fit 6-8 readable graphs here. If no data are available for a particular measures either create “empty” run list the name of the measure(s) to be collected.) Self Assessment Score, 1-5 (see AHA/HRET Assessment Scale document) = Self Assessment Score, 1-5 (see AHA/HRET Assessment Scale document) =

25. Sample Completed Report 25

26. Project Assessment Scale http://www.k- hen.com/Portals/16/Documents/HRETHEN ProjectAssessmentScale.pdf http://www.k- hen.com/Portals/16/Documents/HRETHEN ProjectAssessmentScale.pdf 26

27. Homework Set up CDS users for your site Collect and enter baseline data by Aug 31 Enter monitoring data for Jan - Jun 2012 as available Enter monitoring data for Jul 2012 by Aug 31 Complete July progress report by Aug 31 and email to info@k-hen.cominfo@k-hen.com 27

28. Questions 28