Transcript Slide 1

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
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Introductions
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
Terri Conner, PhD
Project Manager, Nybeck Analytics

Lisa Kerber, PhD
Data Manager, Nybeck Analytics
Summary of this
Presentation
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
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
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
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
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:
Adverse
drug events
Catheter-associated
urinary tract infections
Central line-associated
blood stream infections
Injuries from falls and
immobility
Obstetrical adverse events
Pressure ulcers
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Surgical
site infections
Venous thromboembolism
Ventilator-associated
pneumonia
Preventable readmissions
In addition:
–Safety
culture
–Leadership
Data-Related Requirements
of Hospitals
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
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?
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
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*
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*Donabedian
Arriving at Proposed Metrics
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
Literature Review

Data Advisory Council

Comparison to other HENs’ Plans

TCQPS HEN Online Survey on Data and Metrics
Proposed Outcomes Table
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HAC
Ref
Source
Num 1
Den 1
CAUTI
CDC
NHSN
N UTI
N Cath Days
CLABSI
CDC
NHSN
N BSI
N CL Days
SSI
CDC
NHSN
N SSI
N Pts
Injuries
CMS
Billing
N Pts w/dx
N Dsch
PU
CMS
Billing
N Pts w/dx
N Dsch
Readmit
CMS
Billing
N Readmits w/in 30d
N Dsch prior mo
ADE
IHI
Chart Rev
N ADE
N Total Doses
VTE
NQF
Chart Rev
N no prophy prior to
dx test
N confirmed VTE
OB
NQF
Billing & CR
N birth trauma dx
N elective deliveries
37-39 wks
VAP
CDC
NHSN
N VAP dx
N vent days
Num 2
N Charts & N ADEs by
severity*
Currently Proposed Outcomes
Metrics
CDC NHSN and/or state reported data:

CAUTI:


CLABSI: (by unit)


N CLABSI/Total N CL days
SSI: hip & knee arthroplasties, CABG, colon, ab
hysterectomies, vascular procedures, etc


N CAUTI in unit/Total N catheter days
N pts with SSI/Total N pts with procedure
VAP: CDC NHSN

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N VAP/N ventilator days
Currently Proposed Outcomes
Metrics
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

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N patients readmitted within 30 days/N patients discharged in prior
month
Currently Proposed Outcomes
Metrics
Calculated by CMS with claims/billing/financial data: Hospital
will replicate

Injuries from falls and trauma
–

Pressure ulcers
–
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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
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)

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

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N babies with any birth trauma diagnosis/N babies with elective
delivery between 37 and 39 weeks
Currently Proposed Outcomes
Metrics (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.
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Conferring Rights to
TCQPS in NHSN
THA Information:
 Group Name: THA TCQPS
 Group ID: 19288
 Group Joining Password:
tcqpspfp
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Currently Proposed Process
Metrics

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:
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
N catheter days/N patient days
Currently Proposed Process
Metrics
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

SSI:
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Sterile gloves, gown, cap, mask, drape

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
Metrics

Injuries from falls and immobility
–
Risk assessment on admission: Random chart review


Pressure ulcers
–
PU Prevention protocol: 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

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N Charts with proper documentation of adherence/Total N Charts reviewed
PU assessment on admission: Random chart review


N Charts with risk assessment documentation/Total N Charts reviewed
N Charts with unreconciled medications at discharge/Total N Charts reviewed
Currently Proposed Process
Metrics (Continued)

Obstetrical adverse events: NQF
Elective deliveries < 39 weeks:

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N pts delivering between 37 and 39 weeks/N pts with elective
deliveries
Currently Proposed Process
Metrics (Continued)

VTE: Reportable to CMS
1.
SCIP: VTE 1, 2 prophylaxis

2.
STK: VTE 1 prophylaxis

3.
N patients prophylaxis/N total patients
N patients prophylaxis/N total patients
VTE:
•
1,2: prophylaxis

•
5: Discharge instructions


N patients prophylaxis/N total patients
N patients discharge inst documentation/N total patients
VAP: NQF/IHI
Adherence to vent bundle
1.
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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 (Continued)

ADE – IHI
Medication Reconciliation: Admission, Transfer, Discharge
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N
pts with Med Rec documentation/N charts reviewed
N
pts with Unreconciled medication/N charts reviewed
Proposed Process Table
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HAC
Source
Num 1
Den 1
Num 1
Den 2
CLABSI
NHSN
N insertions w/100%
adherence to bundle
N insertions
Injuries
CR
N risk assessment
upon admission
N Charts
reviewed
PU
CR
N PU assessment
N Charts
reviewed
Readmit
CR
N Discharge checklist
complete
N Charts
reviewed
N Med Rec at
Discharge
N Charts
reviewed
ADE
CR
N pts with Med Rec
at adm, tx, dsch
N Charts
reviewed
N pts with UnRec
Med
N Charts
reviewed
OB
Billing/CR
N elective deliveries
37-39 wks
N elective
deliveries
VAP
CR
N 100% adherence to
bundle
N pts on
Mech Vent
Proposed Process Table
HAC
Source
Possible Num(s)
CAUTI
NHSN/CR
1.
2.
3.
4.
SSI
NHSN/CR
Documentation of adherence to
SCIP bundle
VTE
CR
1.
2.
3.
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N personnel
insert/maintain caths &
have proper training
N pts on unit with cath &
proper assessment of dc
N pts with proper
documentation of
indication
N catheter days
4.
SCIP VTE 1, 2: N pts with
prophylaxis
STK: VTE 1: N pts with
prophylaxis
VTE 1,2: N pts with
prophylaxis
VTE 5: Discharge
instructions
Possible Den(s)
1.
2.
3.
4.
N personnel
insert/maintain caths
N pts on unit with cath
N pts on unit with cath
N pt days
N surgical patients
N total pts
Expected Timeline Associated
with Metrics
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.
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Next steps for your
hospital

Complete our on-line survey on HAC measures?
–

Communicate to TCQPS historical performance in the 10
HACs
–
–
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Please contact Lisa Kerber at [email protected]; she will send
you link to survey
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




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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






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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

PfP Community of Practice: Register at
http://www.healthcarecommunities.org/
–

TCQPS HEN’s data portal--due early Spring 2012
–

TCQPS HEN Community of Practice: after registering for
PFP and TCQPS HEN, then go to ‘Communities’
www.texashospitalquality.org
Questions? Contact: Terri Conner, PhD, at Nybeck
Analytics, [email protected], 512-796-1099
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