MHA: Strategic Quality What’s Up Wednesday | Lunch and LearnYour clinical quality, process improvement resource

What is this about? MHA’s Strategic Quality Initiatives Review 2012-2014 Hospital

Engagement Network performance Preview 2015 Missouri preferred

measures Foundation for future work HIDI

Quality Collections Analytic Advantage+

Upcoming Events

MHA:SQI - Who are we?

Leslie Porth, PhD-C, MPH, R.N.

Division Vice President for Strategic Quality

Improvement

Triple AimPopulation Health

Oversight of division (Quality Improvement, Quality Works,

Emergency Preparedness)MONL

Alison Williams, R.N., BSN, MBA-HCM

Vice President of Clinical Quality Improvement

Clinical quality SMEOversight of Quality

ImprovementGrant management

Collaboratives managementMONL

MOAHQ

Dana Downing, B.S., MBA-H, CPHQ

Director of Quality Program Development

Patient and family engagement

National quality measures Quality outcome transparency

Electronic clinical quality measures

MBQIP grant leadMOAHQ

Jessica Rowden, R.N., BSN, MHA

Clinical Quality Improvement Manager

Clinical quality SMEData management and

analyticsHEN/AHRQ grant projects

TeamSTEPPSHost of WUW|LNL

MOAHQMONL

Cheryl EadsExecutive Assistant of Quality Improvement

Provides support to the SQI team

Coordinates webinars, conference calls and meetings

Distributes correspondence and communication

Assists in maintaining reports

Lporth@mhanet.com573/893-3700x1305

Awilliams@mhanet.com573/893-3700x1326

Ddowning@mhanet.com

573/893-3700x1314

Jrowden@mhanet.com573/893-3700x1391

Ceads@mhanet.com573/893-3700x1382

MHA:SQI - What do we do?

Research, develop, and promote a focused strategy to reduce variation and improve care.

Together we lead the efforts in every Missouri community for better health, better care, and lower costs.

Value Added Member Benefits Include:

•1:1 quality and process consultation

•Networking platform

•Data management and analytics

•Best practice portal

MHA:SQI - Where are we?

Physically: offices based in Jefferson City Virtually: http://web.mhanet.com/strategic-quality/

New Webspace where you can learn about– MHA SQI – News worthy items– Upcoming events and registration links– List of partners– Pool of resources

Trajectories – Triple Aim publication available first Wednesday of the month

2012-2014 Hospital Engagement Network Performance

CMS Partnership for Patients Grant 3,700 hospitals participating 26 National HENs: AHA/HRET, Premier, Ascension, eHEN,

UHC, Childrens, etc. AHA/HRET HEN – MHA was one of 31 State Hospital Association HENs– Ninety-three hospitals in Missouri were part of our cohort

P4P Grant sunset on December 8, 2014 Quality improvement work continues

2012-2014 Hospital Engagement Network Performance

MO-40/20 Achievement in 6 Topics

2012-2014 Hospital Engagement Network PerformanceMissouri HEN 1.0 Estimated Cost Savings

Source: Methodology and average costs provided through HRET; n=93

Adverse eventPercent

Improvement(Goal 40 percent)

# harms prevented Average cost/harm Cost savings

ADE (adverse drug events)

15% -489 $3,000 ($1,467,000)

Birth Trauma 61% -24 $920 ($22,080)

CAUTI (urinary tract infection)

2% -202 $1,000 ($202,000)

CLABSI (central line infection)

100% 2 $17,000 $34,000

EED (early elective deliveries)

64% 291 $7,875 for 9.96% cases $228,246

Falls with Injury 28% 434 $663 $287,742

Readmissions 7% (goal 20%) 8,923 $10,100 $90,122,300

SSI (surgical site infection)

50% 160 $21,000 $3,360,000

Stage III/IV Pressure Ulcer

62% 11 $40,500 $445,500

VAP (ventilator pneumonia)

0% -8 $21,000 ($168,000)

VTE (blood clot) 45% -38 $22,240 ($845,120)

Total 9,060   $ 91,773,588

MHA:SQI Guiding force

Strategic Quality Advisory Committee Comprised of 22 Missouri CEOs, CMOs, CNOs, QD Provides feedback and direction for quality

improvement strategies Meet quarterly

Quality Taskforce Workgroups Recruitment is in process Readmission/Care Coordination & Clinical Excellence Quality director and front line engagement focused

2015 Missouri Preferred Measures

Topic Analysis: Measure Selection

Quality of measure• Validity – NQF endorsed• Reliability – defined numerator

and denominator• HEN, eCQM, ACO• Claims data to reduce hospital

burdenFinancial implications

• Regulatory impact• Value-based purchasing• Readmission reduction• Harm – HAC

Ability to improve• Variation across state• Variation from goal

Population health• Align with CHNA• Impact through continuum• Care transitions

Broader importance• Upstream – advocacy • Downstream – consumers• Hospital Compare

Foundation for future quality work

High reliability organization principles Triple Aim framework Safety across the board Transparency Patient and Family Engagement Immersion/Pilot Projects HEN 2.0

2015 and beyond: HRO

High Reliability Organizations Principles of an HRO

Healthy preoccupation with failure Reluctance to simplify Sensitivity to operations Commitment to resilience Deference to expertise

2015 and Beyond: 3A

Adopt the Triple Aim Framework Better care, better health, lower cost

Implement strategies to Coordinate care across the continuum Integrate prevention, preparedness and population health

Engage new partnerships Physicians Provider organizations External stakeholders

Utilize Evidence-based approaches Data to analyze, guide and evaluate

2015 and beyond: SAB

Safety = top priority of every hospital Safety Across the Board

Establish a culture of safety Engage the patient and family Create safety across the board Count all harms

Webinar: Wednesday, Jan. 28, from 12 to 1:00 p.m.: Clinical Excellence, Safety Across the Board

2015 and beyond: Transparency

2015 Quality Dashboards developed for hospital review Based on 2015 preferred measures Consumer website development

2016 Public transparency for preferred measures and price Consumer website available

Monday, Jan. 26, from 11 to 12:00 p.m: MHA Quality Transparency Plan

2015 and beyond: PFE

MHA has a patient/family advisor to help guide strategy Additional toolkits and resources will be made available in

2015 Goal = PFAC development in every hospital

HIDI

www.hidianalyticadvantage.com Quality Collections – data reporting

Data reporting portal to house hospital abstracted data for reporting purposes

Analytic Advantage+ – report generator Offers reports for participating hospitals’ specific reporting

needs. Hospital staff has the ability to view, download and directly interact with data to assist with decisions in improving hospital operations

Focused quality reports defined and distributed by MHA

Upcoming Events

January Monday, Jan. 26, from 11 to 12:00 p.m – Webinar: MHA Quality

Transparency Plan– Participant dial-in number: 888/822-3280; participant code: 604620.– Register

Wednesday, Jan. 28, from 10 to 11:30 a.m. - Webinar:  “Revenue Cycle Improvement: Tracking Reimbursement”

Wednesday, Jan. 28, from 12 to 1:00 p.m. – Webinar: Clinical Excellence, Safety Across the Board– Participant dial-in number: 866/675-1560; Participant code:  9427102256– Register

Upcoming Events, cont.

February Feb. 4, from Noon to 1 p.m. - Lunch & Learn: What's Up

Wednesday HEN End of Project Report released Falls Toolkit released

WUW|LNL – first Wednesday of the month from Noon to 1:00 p.m.

Regional workshops in April Quality 101 Conference in May Visit our website for additional events and links