Partnership for Patients Safe Deliveries Roadmap Safe Table November 19, 2013 Presented at Washington State Hospital Association Safe Table 11/19/2013

CME Credits You will receive an with a link to the evaluation form. After you complete the evaluation, you will be redirected to a CME credit claim form where you will enter the number of credits you are claiming. Once you click “submit,” you will receive your CME certificate automatically. Nurses can claim Category 1 credit toward their state relicensure. Presented at Washington State Hospital Association Safe Table 11/19/2013

Safe Tables Confidential Safe All teach All learn Presented at Washington State Hospital Association Safe Table 11/19/2013

Partnership for Patients 40 – Percent reduction in harm 20 – Percent reduction in readmissions 13 – by 2013 Presented at Washington State Hospital Association Safe Table 11/19/2013

10 Targeted Strategies Infection Reduction: 1.Catheter-associated urinary tract infections (CAUTI) 2.Central line-associated blood stream infections (CLABSI) 3.Surgical site infections (SSI) 4.Ventilator-associated pneumonia (VAP) Nursing Care: 5.Injuries from falls and immobility 6.Pressure ulcers High Risk: 7.Adverse drug events 8.Obstetrical adverse events 9.Venous thromboembolism or blood clots (VTE) Continuity of Care: 10. Prevention of readmissions Presented at Washington State Hospital Association Safe Table 11/19/2013

OB Adverse Events Partnership for Patients: 2012 – 2013 Early Elective Delivery Prior to 39 Weeks Episiotomy Safe Deliveries Roadmap Partnership for Patients: 2014 Early Elective Delivery Prior to 39 Weeks Episiotomy Safe Deliveries Roadmap Pre-eclampsia Hemorrhage Presented at Washington State Hospital Association Safe Table 11/19/2013

Submission rates for most recent quarter: CLABSI: 93.8% VAP: 93.9% CAUTI: 93.8% SSI: 94.4% Falls: 57.8% Pressure Ulcers: 90.3% EED: 84.1% VTE: 85.2% Readmission: 100.0% ADE: 31.2% Leadership, Patient and Family: 79.6% Goal 40% Goal 20% Below the Line is Better OB CLABSI VAP CAUTI SSI ADE Readmissions Pressure Ulcers Falls 32% 89% 18% 46% 90% 12% Baseline 2010 VTE* Based on submitted data through Q for CLABSI-ICU, CAUTI-ICU, SSI, and VAP Based on submitted data through Q for Falls, OB, OB-Episiotomy, Pressure Ulcers, and VTE Based on submitted data through Q for Readmissions Based on submitted data through July 2013 for ADE-Anticoagulants *Current rate is equal to baseline rate Achieve by December 2013 Harm and Readmissions Reduction Results 54% Green – Reached Goal Yellow – Moving in Right Direction Red – Work to be Done 11/9/ % OB- Episiotomy 32% Presented at Washington State Hospital Association Safe Table 11/19/2013

Progress To date, Washington State Hospital Association hospitals working together have achieved: 90% reduction in early elective deliveries – resulting in over 1,900 babies allowed to mature and $5 million in savings 89% reduction in ventilator-associated pneumonia from baseline – resulting in two fewer patients experiencing ventilator-associated pneumonia a week, saving $3.5 million 43% reduction in stage II, III and IV (or unstageable) pressure ulcers– resulting one fewer patient experiencing a pressure ulcer a week, saving $2.2 million 32% reduction in ICU central-line associated bloodstream infections from baseline – resulting in one fewer patient experiencing a central-line associated bloodstream infection a week, saving $1 million Presented at Washington State Hospital Association Safe Table 11/19/2013

Progress (continued) Washington State Hospital Association hospitals working together have achieved: 21% reduction in surgical site infections from baseline – resulting in two fewer patients experiencing a surgical infection each week, saving $2.5 million 18% reduction in readmissions from baseline – resulting in over 4,000 fewer patients being readmitted to the hospitals a year, $6 million in savings 12% reduction in falls – resulting in one fewer patient falls each week, saving $1 million Presented at Washington State Hospital Association Safe Table 11/19/2013

NEW! Presented at Washington State Hospital Association Safe Table 11/19/2013

Clinicians and Hospitals Leading the Way

U.S. NEWS Volume of deliveries (annual) Average volume of deliveries per attending provider (annual) Availability of an on-site neonatal intensive care unit Availability of certain types of specialists, such as neonatologists Midwife availability Rate of elective deliveries prior to 39 weeks gestational age Risk-adjusted rates of adverse outcomes (maternal and/or infant) Risk-adjusted primary Cesarean- section rate Risk-adjusted VBAC rate Episiotomy rate Breastfeeding rate Appropriate use of antenatal steroids Average length of stay Average cost

Compelling Case

NEW! Presented at Washington State Hospital Association Safe Table 11/19/2013

Partners American Congress of Obstetricians and Gynecologists Association of Women’s Health, Obstetric & Neonatal Nurses March of Dimes Northwest Organization of Nurse Executives Obstetrics Clinical Outcomes Assessment Program Rural Healthcare Quality Network Washington State Department of Health Washington State Health Care Authority Washington State Hospital Association – Partnership for Patients Washington State Medical Association Washington Perinatal Collaborative More to Come….. Presented at Washington State Hospital Association Safe Table 11/19/2013

Project Structure and Process Monthly meetings Bulletin board Newsletters Data reports Participating Hospitals AdvisoryLeadershipMeasuresLEAPT Presented at Washington State Hospital Association Safe Table 11/19/2013

Participating Hospitals Cascade Valley Hospital and Clinics Central Washington Hospital Coulee Medical Center EvergreenHealth Group Health Cooperative Harrison Medical Center Highline Medical Center Island Hospital Jefferson Healthcare Kittitas Valley Healthcare Lake Chelan Community Hospital Legacy Salmon Creek Medical Center Mid Valley Hospital MultiCare Auburn Medical Center MultiCare Good Samaritan Hospital MultiCare Tacoma General Hospital Newport Hospital Othello Community Hospital Overlake Hospital PeaceHealth Southwest Medical Center PeaceHealth St. Joseph Medical Center PeaceHealth Sacred Heart Medical Center, Oregon PMH Medical Center Providence Holy Family Hospital Providence Mt. Carmel Hospital Providence Regional Medical Center Everett Providence Sacred Heart Medical Center & Children’s Hospital Providence St. Mary Medical Center Providence St. Peter Hospital Pullman Regional Hospital Samaritan Healthcare Skagit Valley Hospital St. Elizabeth Hospital St. Francis Hospital St. Joseph Medical Center – Franciscan Health System Sunnyside Community Hospital & Clinics Swedish/Ballard Swedish /First Hill Swedish/Edmonds Swedish /Issaquah Three Rivers Hospital UW/University of Washington Medical Center UW/Northwest Hospital & Medical Center UW/Valley Medical Center Valley Hospital/Rockwood Health System Walla Walla General Hospital Whidbey General Hospital Whitman Hospital and Medical Center Yakima Valley Memorial Hospital Presented at Washington State Hospital Association Safe Table 11/19/2013

Project Leaders Tom Benedetti, MD Dale Reisner, MD Kathleen Simpson PhD, RNC, FAANEric Knox, MD Presented at Washington State Hospital Association Safe Table 11/19/2013

Advisory Group Amy Bertone RN, Providence Health & Services Angela Chien MD, Evergreen Health Ann Darlington CNM, Retired from Group Health Bat-Sheva Stein RN, Department of Health Bruce Myers MD, Omak Deborah Castille RN, PeaceHealth Deborah Saner MD, Legacy Salmon Creek Douglas Madsen MD, PeaceHealth Drew Robilio MD, Franciscan Health System Duncan Neilson MD, Legacy Health System Ellen Kauffman MD, Foundation For Healthcare Quality Frank Andersen MD, Providence Health & Services Helen Phillips RN, Legacy Health System James Wallace MD, Brewster Jane Dimer MD, Group Health Jane Uhlir MD, Swedish Katy Drennan MD, MultiCare Lynn Rhett RN, Franciscan Health System Molly Parker MD, Port Townsend Patrick Moran MD, Yakima Peter Nielsen MD, Madigan Rita Hsu MD, Wenatchee Shelora Mangan RN, Legacy Health System Suzan Bishop RN, MultiCare Susan Walker RN, University of Washington Tracey Kasnic RN, Central Washington Presented at Washington State Hospital Association Safe Table 11/19/2013

Leading Edge Advanced Practice Topics LEAPT Kittitas Valley Healthcare Legacy Salmon Creek Medical Center Overlake Medical Center PeaceHealth St. Joseph Medical Center Providence Holy Family Hospital Providence Sacred Heart Medical Center and Children’s Hospital Providence St Peter Hospital Samaritan Healthcare Swedish/Ballard Swedish/Edmonds Swedish/First Hill Swedish/Issaquah Three Rivers Hospital UW Medicine/Northwest Hospital & Medical Center UW Medicine/Valley Medical Center Whidbey General Hospital Yakima Valley Memorial Hospital Presented at Washington State Hospital Association Safe Table 11/19/2013

Roll-out On-boarding: (July – December) Education Readiness assessment Testing: (October – December) Implementation: (January – December 2014) AND, THEY’RE OFF! Presented at Washington State Hospital Association Safe Table 11/19/2013

What we are learning Since we are charting new waters: Implementation is messy Developing as we go Changing time-lines Course corrections We need to get more comfortable not having the answers “If you are not uncomfortable, you are not learning!” Safety nets are necessary Presented at Washington State Hospital Association Safe Table 11/19/2013

Ralph Stacey Matrix Presented at Washington State Hospital Association Safe Table 11/19/2013

What we are Learning Everyone has something to teach/contribute Need to be sensitive when determining what can be standardized and what should be customized Presented at Washington State Hospital Association Safe Table 11/19/2013

“Haters” “Standardiz ation Polyannas” General attitudes towards standardization: Lessons learned from an attitude survey “Ambivalent” Courtesy of Dr. Keith Georgeson Presented at Washington State Hospital Association Safe Table 11/19/2013

What we are Learning Goodwill keeps things moving when we hit a wall

UPDATES Presented at Washington State Hospital Association Safe Table 11/19/2013

Measures Presented at Washington State Hospital Association Safe Table 11/19/2013

Data Sources California Maternal Data System Obstetrics Clinical Outcomes Assessment Program (OB COAP) Washington State Health Data System Criteria Safe Deliveries Roadmap measures within specified period of time. Data burden on hospitals No duplication of data abstraction Protection from disclosure and discovery – CQIP Ability to drill down to individual cases for quality improvement Hospital and system level reports Costs with Capability for health systems that cross state boundaries to allow all of their hospitals to participate. Decision - l everage strengths of all three systems California Maternal Data System – Safe Deliveries Roadmap outcomes OB COAP – LEAPT project (to be determined) WA state Health Data System – support infrastructure build for future

HIGHER LOGIC

Medicaid Quality Incentive Presented at Washington State Hospital Association Safe Table 11/19/2013

Induction Appropriateness Numerator: number of patients undergoing a medical or non-medical induction with documentation of consent, Bishop score and indication Denominator: Number of patients undergoing a medical or non-medical induction Documentation sources for Bishop score and induction can be taken from the consent, medical record, or checklist available if audited by the Healthcare Authority. Hospitals are encouraged to make a part of the medical record if possible. Consent: For written consent the following is required under RCW (1): Identification of patient Name of hospital in which treatment is to be performed Name of attending physician Nature, anticipated results, alternatives to and risk of proposed treatment, including nontreatment When the proposed treatment will be given Date and time of signing the consent Signature of patient or patient’s representative Witness If hospital does not use a standard consent for all induction patients, the hospital will conduct an audit of a minimum of thirty records randomly selected to review if all elements of consent are present. Audit must be available for the Health Care Authority to review. For hospitals that use on each of their induction patients a standard hospital consent that includes all elements, no audit is needed.

Meeting Schedule 2013 Roadmap Monthly (webcast) Thursday, December 5 th 7:00 – 8:00 a.m. LEAPT Roadmap – kickoff Thursday, December 5 th 7:00 – 8:30 a.m Roadmap Monthly (webcast) 7:00 – 8:00 a.m. Safe Tables (in-person) 9:00 a.m. – 2:30 p.m. April 1 July 24 November 20 CANCELED! January 9 February 21 March 26 April 23 May 20 June 12 July 23 August 19 September 18 October 21 November 26 December LEAPT TBA at Kickoff Presented at Washington State Hospital Association Safe Table 11/19/2013

Thank You! Mara Zabari, Director of Integration Partnership for Patients Safe Deliveries Roadmap Website Presented at Washington State Hospital Association Safe Table 11/19/2013