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Marlyn Conti , BSN, MM, CPHQ Patient Safety Initiatives Manager Intermountain Healthcare

Intermountain-led CMS Hospital Engagement Network Pressure Ulcer Prevention September 23, 2014 Affinity Call. Marlyn Conti , BSN, MM, CPHQ Patient Safety Initiatives Manager Intermountain Healthcare. Outline for Discussion. Review of the HEN Pressure Ulcer work Q1 2014 Data review

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Marlyn Conti , BSN, MM, CPHQ Patient Safety Initiatives Manager Intermountain Healthcare

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  1. Intermountain-led CMS Hospital Engagement Network Pressure Ulcer PreventionSeptember 23, 2014 Affinity Call Marlyn Conti , BSN, MM, CPHQ Patient Safety Initiatives Manager Intermountain Healthcare

  2. Outline for Discussion • Review of the HEN Pressure Ulcer work • Q1 2014 Data review • “Just-one-thing” Recommendations • 2012 Participant survey • 2014 Participant survey • Next steps

  3. Overall Progress Through Q1 2014

  4. Intermountain HEN 2012-Q1 2014 Pressure Ulcer PSI 3 Patients with Stage III, Stage IV or unstageable pressure ulcers

  5. Intermountain HEN 2012-Q1 2014 Pressure Ulcer PSI 3 Patients with Stage III, Stage IV or un-stageablepressure ulcers

  6. Intermountain HEN 2012-Q1 2014 Pressure Ulcer >= Stage 3 Stage 3 or greater from the prevalence survey

  7. Intermountain HEN 2012-Q1 2014 Pressure Ulcer >= Stage 3 Stage 3 or greater from the prevalence survey Decline in denominator in Q1 2014 is due to anomalous data

  8. Intermountain HEN 2012-Q1 2014 Pressure Ulcer >= Stage 2 => Stage 2 added in 2014

  9. Intermountain HEN 2012-Q1 2014 Pressure Ulcer >= Stage 2 => Stage 2 added in 2014

  10. Intermountain HEN 2012-Q1 2014 Pressure Ulcer Prevalence All stages from the prevalence survey

  11. Intermountain HEN 2012-Q1 2014 Pressure Ulcer Prevalence All stages from the prevalence survey Decline in denominator in Q1 2014 is due to anomalous data

  12. High Performing Hospital Highlight… Pressure Ulcers Prevalence

  13. Just One Thing MatrixRecommendations

  14. Intermountain SKIN Bundle

  15. Participant Survey 2012 38% sites at Improvement stage, 26% challenges, 24% sustaining

  16. Participant Survey 2012 Pressure Ulcers ranked at 3rd at 5.13 for priority by the participating hospital

  17. 2014 Pressure Ulcer Survey Report Carlos Barbagelata Intermountain Institute for Healthcare Delivery Research 9/23/14

  18. 1. Do you have a team assigned to work on Pressure Ulcer prevention?

  19. 1a. Is your pressure ulcer prevention team multidisciplinary? (if yes, which disciplines are included)

  20. 1b. How frequently does your Ulcer Prevention team meet? (Check all that apply)

  21. 1c. Does your pressure ulcer prevention team have resources to collect/interpret/review data? (If yes, please explain below)

  22. 2. Do you provide hospital-acquired pressure ulcer reports foruse by hospital staff and teams? (If yes, please describe how reports are distributed or made available)

  23. 2a. Do your reports include prevalence, incidence, or both? 2b. How are reports updated or made available?

  24. 2c. Could you share an example of how the reports are used by hospital staff/teams?

  25. 3. What tools do you use to educate staff about assessment and properly staging pressure ulcers? (check all that apply)

  26. 4. Do you have skin and/or pressure ulcer assessment prompts embedded in your Electronic Medical Record (EMR)?

  27. 4a. How often are the staff prompted to repeat the assessment?

  28. 4b. What EMR vendor is being used?

  29. 4c. What type of assessment is being used?

  30. 5. What is the one intervention that has had the most impact in reducing pressure ulcers at your site in the past two years?

  31. 6. What is the most innovative approach that you feel has contributed to reducing pressure ulcers?

  32. 7. To help us measure progress, please indicate your facility's program status since starting the HEN collaboration to reduce pressure ulcers. What level do you feel your facility is at? A. "Getting Started": This level consists of identifying areas that need the most attention and appointing a leader that will help drive improvement and education SWAT (or champion) teams. B. "Working Harder": This level focuses on adopting decision algorithms for RNs to select appropriate surfaces and independently make decisions. C. "Ahead of the Curve": This level focuses on establishing monthly prevalence studies or incidence rates from Electronic Medical Records (EMR), then feed that data back to the SWAT teams.

  33. 8. What barriers are you experiencing that are preventing you from achieving your goals to reduce pressure ulcers.

  34. 9. What is your role at your facility?

  35. 10. What is the size of your facility?

  36. There’s still time to complete the survey! If the survey has not been completed for you hospital or organization, please go to: https://csbsutah.co1.qualtrics.com/SE/?SID=SV_1XD83SpQdlnNw9f We follow up and develop a resource guide based on the survey responses to be shared across the HEN

  37. 2014 plans for improvement • Quarterly Affinity Calls • 2015 CMS HEN contract renewals - unknown • Sustainability? • Collect and share best practices across our network hospitals & system in a single document

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