1. Cohort 2 + 3+ 4 Coaching Call “Cohort 9” October 15, 2014 Coaches: Tracy Rutland Jean Allred Jan Ratterree Lynne Hall

2. Learn. Act. Improve. Spread. Keep the Drum Beat Going. WELCOME and Introductions 2 What is not started today cannot be finished tomorrow

3. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 3 2014 OAT Survey Reminder October 24 Survey Link Disturbed week of September 29th Comparative survey – No changes in questions from the 2013! Suggested list for gathering input will be included for each domain Due by October 24 th Summary and comparisons back to the hospitals in November Hospitals completing the OAT on time will receive 5 points toward their Leader’s Circle score 3

4. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 4 Best Practice Snapshot Answers will be used for final HEN Recognition Program and Leader’s Circle Designation Failure to submit one survey per hospital will result in the loss of 5 points in the Recognition Program Due Date Friday, October 31 @ midnight http://survey.gha.org/n/BPSS42014.aspx. http://survey.gha.org/n/BPSS42014.aspx Think of it this way Your HEN Option Year 1 Graduation Selfie 4

5. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 5 NOVI reporting of C. difficile Begin surveillance/collection of data October 1 Place October data into GHA Manual Data Entry by November 15 th Contact Jan Ratterree with any questions related to data collection surveillance and/or reporting into NOVI – (770)-240-4518 – jratterree@gha.org 5

6. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 6 What is required in Manual Data Entry to obtain accurate data: Numerator: – The number of C. difficile positive specimens in patients with specimen collection day beginning with > 3 days after admission to the facility (i.e., on or after day 4). Important Numerator Definitions: – A + test for C. difficile is defined as: A positive laboratory test result for C. difficile toxin A and/or B, OR, A toxin-producing C. difficile organism detected by culture or other laboratory means performed on a stool sample. – Do not report a Duplicate toxin-positive laboratory (+) C. difficile toxin test result with prior (+) in ≤ 2 weeks in same patient and same location 6

7. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 7 What is required in NOVI to obtain accurate data: Denominator: – Total number of Patient Days (do not count NICU and Well Baby) – A daily count of the number of patients in the facility inpatient units during a time period. To calculate patient days, for each day of the month, at the same time each day, record the number of patients. At the end of the month, sum the daily counts and enter the total. – If patient days are available from electronic databases, these sources may be used as long as the counts are not substantially different (+/_5%) from manually-collected counts 7

8. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 8 What is required in NOVI to obtain accurate data: Denominator: – We are following inpatients A patient whose date of admission to the facility and the date of discharge are different calendar days. Note: A patient who is admitted to an inpatient location as an “observation” patient is identified as an inpatient on the first and subsequent days for the purposes of surveillance. 8

9. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 9 Readmissions Data 9

10. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 10 Progress Harms Prevented – All HEN Initiative Harms exc. Readmission = 11,414 Harms per day reduced by 38% – All Readmission = 6,799 Readmissions per day reduced by 17% – Total Harms Prevented = 18,213 Dollars Saved from baseline – All HEN Initiatives Harms exc. Readmission = $42,564,288 – All Readmissions = $66,686,860 – Total Dollars Saved through harm prevention = $109,251,148 10

11. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Improvement Rates Summary Post Operative PE/DVT PSI-12 19.13% CAUTI (CMS HAC6) *16.9% Sepsis PSI-13 16.9% ADE-Glycemic Control **10.43% ADE-Anticoagulant Control **@0.9% (well below benchmark) CLABSI SIR 9.82% 11 Hits! Early Elective Delivery 98% Pressure Ulcers PSI-3 Medicare only 42.40% Pressure Ulcers Stage II 33.13% CLABSI ICU 31.19% SSI Hysto SIR* 24.9% Vascular Catheter-Associated Infection (CMS HAC 7) 23.1% Hits are meeting 40/20 percent improvement from baseline or national benchmarks *2011 baseline **2013 baseline

12. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Improvement Rates Summary Misses C-Diff Rate Revised CAUTI Codes 996.64 and 599.0 (HAC26) CAUTI SIR CAUTI SIR (from NHSN) CAUTI Utilization Ratio-General Units CAUTI Utilization Ratio-ICU CAUTI device utilization ratio (NHSN) CAUTI Rate-ICU per 1,000 Catheter Days CAUTI Rate-General units per 1,000 Catheter Days CLABSI SIR (from NHSN) CLABSI Utilization Ratio-General Units CLABSI Utilization Ratio-ICU CLABSI device utilization ratio (NHSN) CLABSI Rate-General Units per 1,000 Central Line Days Falls and Trauma (CMS HAC 5) Falls with Injury (NDNQI) Sepsis Length of Stay Sepsis Mortality Rate Birth Trauma Rate - Injury to Neonate (PSI 17) Obstetric Trauma Rate--Vaginal Delivery with Instrument (PSI 18) Obstetric Trauma Rate- Vaginal Delivery wo Instrument (PSI 19) 30-Day Readmission Rate - Hospital Wide Readmission Rate (CMS Definition) 30-Day Readmission Rate - Medicare Only Medicare FFS 30-Day All-Cause Readmissions SSI: Colon SSI: Hip Replacement SSI: Knee Replacement SSI Colon Surgery SIR (NHSN ) Infection-related Ventilator-Associated Complication Observed Rates for VACs- NHSN Definition Probable VAP 12 Misses are not meeting 40/20 percent improvement from baseline or national benchmarks

13. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Trending Better in CAUTI and CLABSI 13

14. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Surgical Site Infection 14

15. 15

16. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 16 HAC – NOVI data entry 16

17. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 17 HAC – NOVI data entry 17

18. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 18 HAC – NOVI data entry 18

19. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 19 HAC – NOVI data entry 19

20. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 20 HAC – NOVI data entry 20

21. Learn. Act. Improve. Spread. Keep the Drum Beat Going. “It’s a wonderful life” and the HEN Project Consider the past 3 years without the HEN – What has made the difference for your hospital – Tell the “HEN story” for your hospital 21

22. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 22 Cohort “9” – Safety Across the Board Share additional successes on any HEN Topic Best Practice Implementation questions? Any questions/comments regarding measures? 22

23. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 23 Don’t Stop Now What does that mean if you stop making improvements? Another 3,472 avoidable harms will happen in Georgia before the end of the year – Costing more than $12.8 million Almost 8,266 avoidable readmissions will happened before the end of the year – Costing $80 million 23

24. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 24 Upcoming Events Next Cohort Coaching Call: Not Scheduled OB Adverse Event Affinity Webinar: October 22 @ 11 am Data Submission – Aug. Due 10/15 / Sept. Due 11/15 ADE’s including INR, BG, and Opioids Falls with injury VTE-6 (due once a quarter) HAI (if not submitting via NHSN) include CDI EED if applicable GHA Annual Meeting November 13-14 HEN Celebration Webinar scheduled for November 19

25. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 25 EVALUATION Remember Complete the evaluation for today’s Cohort “9” Coaching Call! 25