Montana Regional Meeting Glendive Medical Center AHA/HRET Hospital Engagement Network Charisse Coulombe, MS, MBA, CPHQ; Senior Director, HEN Hospital Engagement Network Health Research & Educational Trust American Hospital Association

Hospital Leadership Clinicians & Front Line Staff (Teams) THE PATIENT ACA considerable focus on quality Created the CMS Innovation Center Public-private partnership Set 40/20 goal Tool: Hospital Engagement Networks 26 contracts awarded Contracted with 31 state and regional hospital associations 1,600 + hospitals Hospital Engagement Network

Partnership for Patients The 40/20 Goal Keep patients from getting injured or sicker Reduce preventable hospital-acquired conditions by 40 percent 1.8 million fewer injuries to patients, with more than 60,000 lives saved over the next three years Help patients heal without complication Reduce all hospital readmissions by 20 percent 1.6 million patients will recover from illness without suffering a preventable complication requiring re-hospitalization within 30 days of discharge 3

Progress to Date EEDs/OB Adverse Events 36%: Average percent reduction in EED > =37 weeks and <39 weeks for 612 hospitals (68%) 2,673 EEDs prevented (all hospitals) $1.9 m Estimated cost savings for avoided EED NICU admissions (all hospitals) Also tracking hard stop policies implemented across all birthing hospitals CAUTIs 9%: Average CAUTI percent reduction in all tracked units for 985 hospitals 359 CAUTIs prevented (all hospitals) $269,000 Estimated cost savings for avoided CAUTIs CLABSIs 11%: Average CLABSI percent reduction in all tracked units for 823 hospitals 308 CLABSIs prevented (all hospitals) $5.8M Estimated cost savings for avoided CLABSIs

Progress to Date ADEs and Falls Focus area for all HENs and all of the states within our HEN Participate in the Boot Camps! PRESSURE ULCERS 2.52Percent reduction in patients with at least one Stage II or greater pressure ulcer for 399 hospitals 8.18Percent reduction in CMS HAC Pressure Ulcers for 367 hospitals Need more data submission from our hospitals! 34 Stage III/IV Pressure Ulcers prevented (all hospitals) $1.4M Estimated cost savings for avoided Stage III/IV Pressure Ulcers SSIs <0.81% Average surgical site infection rate (in hospital) for 808 hospitals <1.26%Average SSI rate (within 30 days of procedure) for 752 hospitals

Progress to Date VTEs 0.57 Average percent reduction in Post-op PE/ DVT (AHRQ PSI 12) rate for 360 hospitals 12.7Average percent reduction in Potentially Preventable VTE for 330 hospitals VAPs 21 Average percent reduction in ventilator-associated pneumonia rate in ICU for 486 hospitals 152ICU VAPs prevented (all hospitals) $6.5m Estimated projected cost savings for avoided ICU VAPs (all hospitals) READMISSIONS 1.8 Average percent reduction for 30 day all cause readmission rate for 829 hospitals 2.7Average percent reduction for Heart Failure 30 day all cause readmission rate for 258 hospitals

Montana Summary Table TopicMost Popular Outcome Measure Avg # Hospitals Reporting Total Eligible Hospitals Percent Reporting BaselineLast 3 monitoring months Percent Reduction ADEMed Errors Req Pharma Intervention 82631% % CAUTIPts Treated with Abx for UTIs 72627%00None CLABSICLABSI Infection Rate 71354%00None EEDTJC EED41331% % OBC-section Delivery Rate 71345% N/A FallsFalls after admission 92635% % Pressure Ulcer Decubitus Ulcer92635%00None

Montana Summary Table TopicMeasureAvg # Hospitals Reporting Total Eligible Hospitals Percent Reporting BaselineQ or last 3 monitoring months Percent Reduction ReadmissionReadmission with same dx % N/A SSISSI Rate (in hospital) 81362% % VAP* VTEPost Op PE/DVT 82631% N/A * Not enough monitoring data submitted to evaluate

What Data is Needed and How Much? CMS’ focus is on outcome measures to track progress of the HENs In order to be included in the HEN/state level analysis, need to submit at least 4 data points Baseline and Monitoring periods are compared Baseline is defined as pre-2012; if you started collecting data after January 2012, we need that data! We will review your first month submitted and use as baseline reference to track your progress

Data Tools for Hospitals to Review Progress Hospital Dashboard – Data Submission Status – Individual Measure Data – Run Charts Hospital CEO Dashboard – Summary of the Hospital Dashboard Both located under Reports in the Comprehensive Data System (CDS)

Intervention Tools Available has many resources Topic specific change packages Topic specific checklists Reference articles Previous recordings of webinars and meetings Leadership, physician, patient/family engagement resources

Next Steps Continue to work towards 40 percent harm reduction and 20 percent readmission reduction Continue to submit data on your measures Continue to track your progress on all topics through the progress reports Continue to share your ideas and tools with others on the LISTSERVs Continue to share your success stories with us, your states and your fellow hospitals

Thank You! AHA/HRET HEN is proud of the accomplishments that have occurred to date and continue to look forward to accelerating the improvement across all topics! We are here to support you in any way possible – General – Data Specific Questions: – Check in with Casey Brewington! 13