Partnership for Patients Safe Deliveries Roadmap Safe Table November 19, 2013

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

2. CME Credits • You will receive an email 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

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

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

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

6. 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

7. 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% Harm and Readmissions Reduction Results Below the Line is Better 21% OB-Episiotomy Pressure Ulcers Readmissions CAUTI CLABSI Falls VAP OB ADE SSI VTE* Achieve by December 2013 Baseline 2010 12% 18% 21% Goal 20% 32% 32% 46% Goal 40% 54% 89% 90% Based on submitted data through Q2 2013 for CLABSI-ICU, CAUTI-ICU, SSI, and VAP Based on submitted data through Q1 2013 for Falls, OB, OB-Episiotomy, Pressure Ulcers, and VTE Based on submitted data through Q3 2012 for Readmissions Based on submitted data through July 2013 for ADE-Anticoagulants *Current rate is equal to baseline rate Green – Reached Goal Yellow – Moving in Right Direction Red – Work to be Done 11/9/2013 Presented at Washington State Hospital Association Safe Table 11/19/2013

8. 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 $5million 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

9. 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

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

11. Clinicians and Hospitals Leading the Way

12. 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

13. Compelling Case • By the age of 44, most U.S. women have given birth. Four million have a baby every year—virtually all of them in the dark about the quality of care provided by their hospital of choice. Yet available evidence suggests that there are dramatic variations in the care women can expect at different hospitals. In Virginia, for example, primary C-section rates vary from under 14% to above 40%. Rates of episiotomies, regarded by many experts as an unnecessary procedure to expand the birth canal, range from 2.5% to more than 50%. • We would publish the Maternity Care Indicators on www.usnews.com, the free news-and-information website published by U.S. News & World Report. The U.S. News site receives more than 20 million unique visitors per month (according to Omniture analytics), and our annual publication of "Best Hospitals" rankings in 16 adult and 10 pediatric specialties consistently produce some of the site's highest-traffic days. Based on our experience publishing Best Hospitals, we expect that the online release of the Maternity Care Indicators will result in significant and immediate public readership. 

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

15. 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

16. Project Structure and Process • Monthly meetings • Bulletin board • Newsletters • Data reports Presented at Washington State Hospital Association Safe Table 11/19/2013

17. 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

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

19. Advisory Group • Amy BertoneRN, 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 • SheloraManganRN, 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

20. Leading Edge Advanced Practice TopicsLEAPT • 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

21. 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

22. 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

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

24. 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

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

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

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

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

29. 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 - leverage 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

30. HIGHER LOGIC

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

32. 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 7.70.060(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.

33. Meeting Schedule CANCELED! 2013 • Roadmap Monthly (webcast) • Thursday, December 5th 7:00 – 8:00 a.m. • LEAPT Roadmap – kickoff • Thursday, December 5th 7:00 – 8:30 a.m. 2014 • 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 2014 LEAPT TBA at Kickoff Presented at Washington State Hospital Association Safe Table 11/19/2013

34. Thank You! Mara Zabari, Director of Integration Partnership for Patients 206-216-2529 maraz@wsha.org Safe Deliveries Roadmap Website http://www.wsha.org/0513.cfm%20 Presented at Washington State Hospital Association Safe Table 11/19/2013