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Partnership for Patients. TCQPS Hospital Engagement Network: Determining our Metrics Data and Metrics Webinar Feb. 29 at 10:00 and Mar. 8 at 2:00 2012. Introductions. Terri Conner, PhD Project Manager, Nybeck Analytics Lisa Kerber, PhD Data Manager, Nybeck Analytics.

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Tcqps hospital engagement network determining our metrics data and metrics webinar

Partnership for Patients

TCQPS Hospital Engagement Network:

Determining our Metrics

Data and Metrics Webinar

Feb. 29 at 10:00 and Mar. 8 at 2:00

2012


Introductions
Introductions

  • Terri Conner, PhD

    Project Manager, Nybeck Analytics

  • Lisa Kerber, PhD

    Data Manager, Nybeck Analytics


Summary of this presentation
Summary of this Presentation

Goals of Partnership for Patients by end of 2013

Purpose of metrics

Data requirements for hospitals

Our HEN’s currently proposed metrics

How we arrived at the proposed metrics

Timeline associated metrics

Next steps for hospitals

What the TCQPS HEN can do for your hospital

Communication


Purpose of metrics for pfp
Purpose of Metrics for PfP

Goals of Partnership for Patients by End of 2013

Decrease hospital-acquired conditions by 40%, compared to 2010

Decrease preventable readmissions by 20%, compared to 2010

Purpose of Metrics

Aid hospitals and Hospital Engagement Networks in planning and management

Allow transparency on topics that can enable broader financial and political support for related programs

Demonstrate that goals have been achieved


The 10 hospital acquired conditions hacs for initial focus by the pfp are
The 10 hospital-acquired conditions (HACs) for initial focus by the PfP are:

Adverse drug events

Catheter-associated urinary tract infections

Central line-associated blood stream infections

Injuries from falls and immobility

Obstetrical adverse events

Pressure ulcers

  • Surgical site infections

  • Venous thromboembolism

  • Ventilator-associated pneumonia

  • Preventable readmissions

  • In addition:

    • Safety culture

    • Leadership


Data related requirements of hospitals
Data-Related Requirements of Hospitals by the PfP are:

At least one process measure for each focus area (9 HACs, all-payer preventable readmissions)

At least one outcome measure for each focus area

Our goal is to have one numerator and one denominator for each metric

Submit monthly data:

Baseline Process and Outcome: 6-24 months (2010 and 2011)

Initiative Process and Outcome: 12-24 months (2012 and 2013)

Complete Hospital Survey on Patient Safety Culture at program onset and once every 12-18 months for duration of program, with at least a 60% response rate from each unit

Attend TeamSTEPPS training and provide information on how tools in the model will help you achieve your goals (will receive CEs)

Complete other surveys and interviews as needed


Quality improvement why both process and outcomes measures
Quality Improvement: by the PfP are:Why both Process and Outcomes Measures?

  • Structure measures assess the accessibility, availability, and quality of resources, such as health insurance, bed capacity of a hospital, and number of nurses with advanced training.

  • Process measures assess the delivery of health care services by clinicians and providers, such as using guidelines for care of mechanically ventilated patients.

  • Outcome measures indicate the final result of health care and can be influenced by environmental and behavioral factors. Examples include mortality, patient satisfaction, and improved health status.


Qi model
QI Model* by the PfP are:

*Donabedian


Arriving at proposed metrics
Arriving at Proposed Metrics by the PfP are:

  • Literature Review

  • Data Advisory Council

  • Comparison to other HENs’ Plans

  • TCQPS HEN Online Survey on Data and Metrics


Proposed outcomes table
Proposed Outcomes Table by the PfP are:


Currently proposed outcomes metrics
Currently Proposed Outcomes Metrics by the PfP are:

CDC NHSN and/or state reported data:

CAUTI:

N CAUTI in unit/Total N catheter days

CLABSI: (by unit)

N CLABSI/Total N CL days

SSI: hip & knee arthroplasties, CABG, colon, ab hysterectomies, vascular procedures, etc

N pts with SSI/Total N pts with procedure

VAP: CDC NHSN

N VAP/N ventilator days


Currently proposed outcomes metrics1
Currently Proposed Outcomes Metrics by the PfP are:

Calculated by hospital using claims/billing/financial data:

All-Cause Readmissions

If you are in Project RED, continue with the methods your hospital has already developed

If you are not in Project RED, we are recommending that you focus on one or more core condition (AMI, PN, CHF) and calculate raw rates

We also recommend that you include All Payer, not just Medicare patients

N patients readmitted within 30 days/N patients discharged in prior month


Currently proposed outcomes metrics2
Currently Proposed Outcomes Metrics by the PfP are:

Calculated by CMS with claims/billing/financial data: Hospital will replicate

Injuries from falls and trauma

N pts with diagnosis codes as secondary (2-9) with a POA of N or U, designated as CC or MCC/N discharges during time period

Pressure ulcers

N pts with diagnosis codes as secondary (2-9) with a POA code of N or U (707.23, 707.24)/N discharges during time period


Currently proposed outcomes metrics continued
Currently Proposed Outcomes Metrics by the PfP are:(Continued)

  • VTE: NQF

    Incidence of potentially preventable VTE:

    • N Pts who receive no prophylaxis prior to VTE diagnostic test order date/N Pts who develop confirmed VTE during hospitalization

  • Obstetrical adverse events: NQF

    Incidence of birth trauma in elective deliveries < 39 wks

    • N babies with any birth trauma diagnosis/N babies with elective delivery between 37 and 39 weeks


  • Currently proposed outcomes metrics continued1
    Currently Proposed Outcomes Metrics by the PfP are:(Continued)

    • ADE – IHI

      Random chart review; use of trigger tool*. 10 charts/q2wks for a total of 20 charts/mo

      • N of adverse drug events/N total doses

      • N ADEs by NCC MERP

        * Rozich et al. Qual Saf Health Care 2003;12:194-200.


    Conferring rights to tcqps in nhsn
    Conferring Rights to TCQPS in NHSN by the PfP are:

    THA Information:

    • Group Name: THA TCQPS

    • Group ID: 19288

    • Group Joining Password:

      tcqpspfp


    Currently proposed process metrics
    Currently Proposed Process Metrics by the PfP are:

    CAUTI:

    1. Compliance with educational program:

    N personnel who insert/maintain urinary caths and have proper training/N personnel who insert/maintain caths

    2. Compliance with documentation of insertion and removal days

    Random audits

    N patients on unit with cath with proper documentation of insertion and removal dates/N patients on unit with cath in place

    3. Compliance with documentation of indication for cath placement

    Random audits

    N patients on unit with cath with proper documentation of indication/N patients on unit with cath

    4. Catheter Utilization Ratio:

    N catheter days/N patient days


    Currently proposed process metrics1
    Currently Proposed Process Metrics by the PfP are:

    CLABSI:

    Adherence to bundle: N adherence/N total insertion

    Hand hygiene

    Skin prep – CHG

    Skin prep agent completely dried

    All 5 maximal sterile barriers used

    Sterile gloves, gown, cap, mask, drape

    SSI:

    Adherence to SCIP measures: N adherence/N surgical patients

    SCIP 1, 2, 3: Prophylactic abx

    SCIP 4: Glucose

    SCIP 6: Hair removal

    SCIP 9: Post op cath dc’d

    SCIP 10: Temp


    Currently proposed process metrics2
    Currently Proposed Process Metrics by the PfP are:

    Injuries from falls and immobility

    Risk assessment on admission: Random chart review

    N Charts with risk assessment documentation/Total N Charts reviewed

    Pressure ulcers

    PU Prevention protocol: Random chart review

    N Charts with proper documentation of adherence/Total N Charts reviewed

    PU assessment on admission: Random chart review

    N Charts with PU assessment documentation/Total N Charts reviewed

    Preventable readmissions

    Discharge checklist: Random chart review

    N Charts with discharge checklist documentation/Total N Charts reviewed

    Medication reconciliation: Random chart review

    N Charts with unreconciled medications at discharge/Total N Charts reviewed


    Currently proposed process metrics continued
    Currently Proposed Process Metrics by the PfP are:(Continued)

    • Obstetrical adverse events: NQF

      Elective deliveries < 39 weeks:

      • N pts delivering between 37 and 39 weeks/N pts with elective deliveries


    Currently proposed process metrics continued1
    Currently Proposed Process Metrics by the PfP are:(Continued)

    • VTE: Reportable to CMS

      • SCIP: VTE 1, 2 prophylaxis

        • N patients prophylaxis/N total patients

      • STK: VTE 1 prophylaxis

        • N patients prophylaxis/N total patients

      • VTE:

        • 1,2: prophylaxis

          • N patients prophylaxis/N total patients

        • 5: Discharge instructions

          • N patients discharge inst documentation/N total patients

    • VAP: NQF/IHI

      Adherence to vent bundle

      • HOB elevation; 2. Sedation; 3. TSB; 4. Pressure Ulcer and DVT prophylaxis

        • N pts with bundle documentation/N pts on Mech Vent


    Currently proposed process metrics continued2
    Currently Proposed Process Metrics by the PfP are:(Continued)

    • ADE – IHI

      Medication Reconciliation: Admission, Transfer, Discharge

      • N pts with Med Rec documentation/N charts reviewed

      • N pts with Unreconciled medication/N charts reviewed


    Proposed process table
    Proposed Process Table by the PfP are:


    Proposed process table1
    Proposed Process Table by the PfP are:


    Expected timeline associated with metrics
    Expected Timeline Associated with Metrics by the PfP are:

    March 2012: HEN works with hospital HAC teams to finalize metrics.

    March-April 2012: Hospital HAC teams gather baseline data as far back to 2010 as possible; HAI HAC teams allow TCQPS NHSN access.

    April-May 2012: TCQPS launches data portal and HAC teams submit baseline data. TCQPS will extract NHSN data.

    May-Dec 2012: HAC teams continue to gather and submit monthly data.

    July 2012-Dec 2013: HEN distributes reports to hospital HAC teams on a quarterly basis.


    Next steps for your hospital
    Next steps for your hospital by the PfP are:

    • Complete our on-line survey on HAC measures?

      • Please contact Lisa Kerber at Lisa@nybeck.net; she will send you link to survey

    • Communicate to TCQPS historical performance in the 10 HACs

      • 2010-2011

      • How do you currently measure the 10 HACs

      • Send in HAC Team forms, which describe your internal teams for each HAC.

      • How do you currently measure your safety culture? HSOPS? Other survey? How often?


    What the tcqps hen and pfp can do for your hospital
    What the TCQPS HEN and PfP Can Do for your Hospital by the PfP are:

    • Regional face-to-face best practice sharing events annually

    • Peer-to-peer training opportunities

    • Leadership, Culture, Physician, Board & Pharmacy education & training

    • Annual stipend per hospital for travel to regional meetings


    What else the tcqps hen and pfp can do for your hospital
    What by the PfP are:else the TCQPS HEN and PfP Can Do for your Hospital

    • Monthly webinars/conference calls to discuss new ideas, barriers, processes, etc.

    • Partnership with other HENs & QIO to share information & best practices

    • Online Communities of Practice

    • Measure & track hospital performance

    • Site visits to participating hospitals to assist teams

    • Assist your hospital in reaching the PfP goals


    Communication
    Communication by the PfP are:

    PfP Community of Practice: Register at http://www.healthcarecommunities.org/

    TCQPS HEN Community of Practice: after registering for PFP and TCQPS HEN, then go to ‘Communities’

    TCQPS HEN’s data portal--due early Spring 2012

    www.texashospitalquality.org

    Questions? Contact: Terri Conner, PhD, at Nybeck Analytics, terri@nybeck.net, 512-796-1099