Data Office Hours
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Title Block Data Office Hours January 2014 Dolores Hagan, RN, BSN K-HEN Education/Data Manager Debbie Campbell, RN-BC, MSN CCRN K-HEN Improvement Advisor
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Data Office Hours. Title Block. January 2014 Dolores Hagan, RN, BSN K-HEN Education/Data Manager Debbie Campbell, RN-BC, MSN CCRN K-HEN Improvement Advisor. Agenda. Review of participation levels and requirements Discuss measure specifications Examine appropriate sampling techniques - PowerPoint PPT Presentation
Transcript of Data Office Hours
Title BlockData Office HoursJanuary 2014
Dolores Hagan, RN, BSNK-HEN Education/Data Manager
Debbie Campbell, RN-BC, MSN CCRN K-HEN Improvement Advisor
Agenda
• Review of participation levels and requirements
• Discuss measure specifications• Examine appropriate sampling techniques• Demonstrate data collection tool• Harm Across the Board Template
Commitment Letter
• Background – CMS statement of work (SOW)– Continue the 40/20 reduction of harm goal– Ten focus areas with specific areas of focus
defined– Includes
• Patient and family engagement (PFE)• Leadership• Healthcare disparities• Teamwork and communication• Measurement
Participation Levels
• CMS scoring—HEN, State and Hospital level– Participation level– Improvement level– LOP (Z – 5)
• K-HEN Participation requirements defined by the CMS scoring document– Minimum level yields minimum score– Full level yields maximum score
K-HEN Incentive Plan
• K-HEN defined• Not all states in the HRET HEN are
doing this• Structured around
– the level of participation– Timeliness of data submission
Data Submission Schedule
Period Recommended Data Submission Schedule
(All except Readmissions & SSI)
Jan 2014 Mar 1, 2014Feb 2014 Apr 1, 2014Mar 2014 May 1, 2014Apr 2014 Jun 1, 2014
May 2014 Jul 1, 2014Jun 2014 Aug 1, 2014Jul 2014 Sep 1, 2014
Aug 2014 Oct 1, 2014Sep 2014 Nov 1, 2014Oct 2014 Dec 1, 2014Nov 2014 Jan 1, 2015Dec 2014 Feb 1, 2015
Period Recommended Data Submission Schedule
Jan 2014 Apr 1, 2014
Feb 2014 May 1, 2014
Mar 2014 Jun 1, 2014
Apr 2014 Jul 1, 2014
May 2014 Aug 1, 2014
Jun 2014 Sep 1, 2014
Jul 2014 Oct 1, 2014
Aug 2014 Nov 1, 2014
Sep 2014 Dec 1, 2014
Oct 2014 Jan 1, 2015
Nov 2014 Feb 1, 2015
Dec 2014 Mar 1, 2015
Measures by AreaAdverse Event Area (AEA)
Measures
Adverse Drug Events (ADE)
• Excessive anticoagulation (EOM-12)• Glucose control (EOM-13)• Opioid safety (EOM-111)• An overall measure of ADEs (EOM-112)
Falls • Falls with or without Injury (EOM-37)• Falls with injury (minor or greater) (EOM-38)
Pressure Ulcer • Stage II or Greater hospital acquired (EOM-58)• Stage III or IV greater subset (AHRQ PSI 3) (EOM-61)
VTE • Post-op PE or DVT (AHRQ PSI 12) (EOM-105)• Potentially preventable VTE (EOM-104)
EED • Early Elective Delivery (JC PC-01) (EOM-40)
Measures by AreaAEA MeasuresOther OB • Birth Trauma Rate – Injury to Neonate (AHRQ PSI 17) (EOM-
48)• OB Trauma rate-vaginal delivery with instrument (AHRQ 18) (EOM-54)
• Birth Trauma Rate-vaginal delivery without instrument (AHRQ 19) (EOM-55)
• OB Hemorrhage (EOM-118)• Preeclampsia treatment and management to prevent morbidity and mortality (EOM-120)
Readmissions • Diagnosis specific 30-Day readmission rate• AMI (EOM-76); Heart Failure (EOM-77); Pneumonia (EOM-78)
• 30-Day All Cause readmission rate (EOM-75)
Measures By AreaAEA MeasuresCAUTI • CAUTI Rate (NHSN/NDNQI) – ICU only (EOM-19)
• CAUTI Rate (NHSN/NDNQI) – All Units (EOM-18)• Catheter utilization ratio (catheter days/patient days) (EOM-21d)• ED Catheterization rate*
CLABSI • CLABSI rate (NHSN/NDNQI) ICU only (EOM-25)• CLABSI rate (NHSN/NDNQI) All Units (EOM-24)• Days Since Last CLABSI*
SSI • Surgical site infection rate (NHSN) for colon and abdominal hysterectomy procedures within 30 days of procedure(EOM-89)
• Surgical site infection rate (NHSN) for four or more procedures within 30 days of procedure**
VAE/VAP • VAC (NHSN) (EOM-96a or EOM-96d)• IVAC (NHSN) (EOM-96b or EOM-96e)• Possible/Probable VAP (NHSN) (EOM-96c or EOM-96f)
Measure Specifications
• Most measures are nationally recognized standard measures– Follow the national specifications– May sample if the specification allows for it
• Non-standard measures– State-wide specifications are under
development– ADE Excessive Anticoagulation example
Auditing Basics
Deborah R. Campbell, RN-BC, MSN, CCRN AlumnaK-HEN Quality Improvement AdvisorKentucky Hospital Association
– A sample is:• A few of many• Part of a whole
– A good sample is something else!
Sampling
• Common Errors:– Too small– Not representative
• Representative samples allow us to make accurate statements about our population as a whole
Obtaining a meaningful sample
– IDEALLY, we would gather data on every instance of the intervention or outcome we are auditing• Example: Med Rec- 100% chart review-
look at every patients admission paperwork– Barriers
• Very large numbers • Limited resources
Obtaining a meaningful sample
– To be statistically relevant as a sample, it is accepted practice to gather at least 20 points of data monthly.• If the total population you are studying or
measuring is < 20/month, each and every item should be audited.
• If the population is larger, sampling techniques are appropriate.
Obtaining a meaningful sample
Avoiding Selection BiasFor items which are consecutive, use the auditing
method of “Every “n”th item”. Using the example of Med Rec again, one
could design the process to audit every 10th admission (assuming there are enough admissions per month (>200) to provide 20 total audits for the month. If there are fewer than that, one could audit every 5th admission, etc.
How to gather a GOOD sample
• Avoiding Selection bias– For measure which require counts or
observations, use the scheduling of days/times per month method.• Using for example CAUTI bundle
compliance, one could design the process to audit:
–All patients with a CVL every Monday, Wednesday and Friday. (or Q Monday)
• Things to consider: differences among days of the week relative to census, staff, types of patients. Now what???
Cont’d
• Rotating audit schedule- more complicated, but may give you better information– Example 1
• Weeks 1 and 3: M, W, F• Weeks 2 and 4: Saturday and Sunday
– Example 2• Weeks1 and 3: M, W, F day shift• Weeks 2 and 4: M, W, F night shift (or Sat, Sun
PM)– Example 3
• Weeks 1 and 2: Med-Surg Units • Weeks 3 and 4: ICUs
Cont’d
• Care team members other than primary RN– Supervisors, charge nurses– Nurses helping out (regular, floated, agency)– PCAs– Ward clerks– X-ray technicians– Respiratory therapists– Transporters– Family members– Patients themselves
Maintenance Takes a Village
PLEASE let us help if this is new for you or you would just like a second opinion or advice from someone outside your everyday work flow!!
502-992-4383
Questions?
Data Collection Tool
• Excel spreadsheet customized to your hospital
• Numerators/Denominators• Process measures
Harm Across the Board
• New HAB template• NOT mandatory—but earns an extra
incentive• K-HEN will help prepare as much as
possible• New Improvement Calculator from HRET
Open Discussion/QuestionsComplete Learning Activity Survey
