glpp hiin data review: micah mha keystone. mi… · 33 20 4 5 5 2 9 3 0 0 0 6 11 0 0 0 0 0 5 10 15...
TRANSCRIPT
GLPP HIIN Data Review: MICAH
MICAH QN Meeting, August 2018
Prepared by: A Syrek
Please note:
▪ These slides use KDS ID; not to be confused with BCBSM ID
▪Please ask Kristy or email [email protected] if you need your KDS ID. (You can also find your hospital KDS ID in KDS)
GLPP HIIN Data Review: MICAH
GLPP HIIN Overview – Top Performers
•Highest 5 performing areas out of 6
• 6/6 over 20% reduction
*Data as of July 20, 2018 for Total Performance
MeasureBaseline
RatePerformance
Rate Improvement SSI-2b (HYST rate) 1.663 1.304 21.55%CLABSI-1b (SIR - ICU only) 0.970 0.761 21.57%
CAUTI-2b (rate - ICU only) 1.364 1.060 22.29%
SSI-1b (HYST SIR) 1.059 0.808 23.70%CAUTI-1b (SIR - ICU only) 1.051 0.797 24.12%
GLPP HIIN Overview – Bottom Performers
•Lowest 5 performing areas out of 6
*Data as of July 20, 2018 for Total Performance
MeasureBaseline
RatePerformance
Rate Improvement PrU-1 (PSI-03) 0.280 0.352 -25.55%SSI-2d (HPRO rate) 1.043 1.200 -15.04%
SSI-1d (HPRO SIR) 0.976 1.102 -12.88%
VAE-3a (VAC) 4.477 4.900 -9.45%Falls-1 0.511 0.518 -1.27%
MICAH – Top Performers
MeasureBaseline
RatePerformance
Rate Improvement SSI-1c (KPRO SIR) 5.727 1.578 72.45%SSI-2c (KPRO rate) 2.427 0.815 66.44%
VTE-1 (PSI-12) 1.936 0.939 51.49%
CDIFF-2 (CDI SIR) 0.720 0.374 48.01%Falls-1 1.235 1.020 17.44%
*Data as of July 20, 2018 for Total Performance
•Highest 5 performing areas out of 12
• 4/5 over 20% reduction
MICAH - Falls with Injury (Falls-1)
0
1
2
3
4
5
6
7
8
47
99
68
04
68
00
12
93
68
05
65
1
60
9
13
00
12
88
11
41
13
77
24
81
11
69
24
87
12
95
53
1
28
60
58
0
34
92
14
7
67
99
74
5
12
30
67
4
68
01
61
8
68
02
80
00
12
18
68
06
68
07
24
85
50
4
11
79
50
34
RA
TE
KDS ID
Performance Rate
Benchmark (1.020)
*Data as of July 20, 2018 for Total Performance (October 2016 – April 2018)
MICAH - Hospital Onset Clostridium difficile Standardized Infection Ratio (SIR) (CDIFF-2)
0
0.2
0.4
0.6
0.8
1
1.2
1.47
45
12
30
11
79
67
4
24
85
24
87
60
9
11
41
67
99
12
95
53
1
13
00
65
1
13
77
68
01
14
7
50
4
24
81
58
0
12
18
61
8
68
02
12
88
68
04
68
00
68
06
12
93
11
69
68
05
28
60
68
07
34
92
80
00
47
99
50
34
RA
TE
KDS ID
Performance Rate
Benchmark (0.3743)
*Data as of July 20, 2018 for Total Performance (October 2016 – December 2017)
MICAH – Perioperative PE or DVT (VTE-1)
0
1
2
3
4
5
6
7
8
13
00
13
77
58
0
12
18
68
04
67
99
12
30
74
5
12
88
65
1
12
93
68
01
12
95
68
06
11
69
11
41
50
4
53
1
11
79
60
9
61
8
14
7
67
4
24
81
68
00
24
85
68
02
24
87
68
05
28
60
68
07
34
92
80
00
47
99
50
34
RA
TE
KDS ID
Performance Rate
Benchmark (0.9389)
*Data as of July 20, 2018 for Total Performance (October 2016 – December 2017)
MICAH – Surgical Site Infection Rate - Total Knee (SSI-2c)
0
0.5
1
1.5
2
2.5
3
3.5
4
4.56
80
4
28
60
47
99
13
77
14
7
61
8
68
05
68
00
12
93
12
18
12
95
67
4
13
00
68
02
12
30
68
07
53
1
12
88
58
0
60
9
24
81
65
1
24
85
67
99
24
87
68
01
11
69
11
79
34
92
68
06
80
00
74
5
11
41
50
4
50
34
RA
TE
KDS ID
Performance Rate
Benchmark (0.8146)
*Data as of July 20, 2018 for Total Performance (October 2016 – December 2017)
MICAH – Surgical Site Infection Standardized Infection Ratio (SIR) - Total Knee (SSI-1c)
0
1
2
3
4
5
6
7
8
9
47
99
13
77
14
7
50
4
68
02
67
4
12
30
68
07
12
88
58
0
12
93
68
00
12
95
68
05
13
00
11
69
11
79
53
1
60
9
12
18
61
8
65
1
24
81
67
99
24
85
68
01
24
87
68
04
28
60
68
06
34
92
74
5
80
00
11
41
50
34
RA
TE
KDS ID
Performance Rate
Benchmark (1.577)
*Data as of July 20, 2018 for Total Performance (October 2016 – December 2017)
MICAH – Bottom Performers
• Lowest 5 performing areas out of 9
MeasureBaseline
RatePerformance
Rate Improvement CDIFF-1 2.831 3.323 -17.37%CAUTI-1a (SIR - all units) 0.374 0.513 -37.31%
CAUTI-2a (rate - all units) 0.495 0.816 -64.83%
SEPSIS-1 (PSI-13) 0.593 1.855 -212.80%MRSA-1 0.023 0.242 -933.38%
*Data as of July 20, 2018 for Total Performance
MICAH - Hospital Onset Clostridium difficile LabID Event (CDIFF-1)
0
10
20
30
40
50
606
79
9
68
01
12
93
12
30
53
1
11
79
68
05
74
5
67
4
24
85
24
87
50
4
12
88
61
8
14
7
13
00
11
69
24
81
58
0
60
9
68
04
13
77
65
1
68
06
68
00
12
18
68
02
12
95
11
41
28
60
68
07
34
92
80
00
47
99
50
34
RA
TE
KDS ID
Performance Rate
Benchmark (3.322)
*Data as of July 20, 2018 for Total Performance (October 2016 – December 2017)
MICAH - Catheter-Associated Urinary Tract Infection Standardized Infection Ratio (SIR) – All (CAUTI-1a)
0
1
2
3
4
5
6
7
68
04
60
9
12
30
67
99
11
41
68
06
53
1
12
18
11
79
65
1
12
88
11
69
68
01
12
93
74
5
12
95
50
4
13
00
58
0
13
77
61
8
14
7
67
4
24
81
68
00
24
85
68
02
24
87
68
05
28
60
68
07
34
92
80
00
47
99
50
34
RA
TE
KDS ID
Performance Rate
Benchmark (0.5133)
*Data as of July 20, 2018 for Total Performance (October 2016 – December 2017)
MICAH - Catheter-Associated Urinary Tract Infection Rate – All (CAUTI-2a)
0
5
10
15
20
25
30
351
16
9
68
01
68
04
60
9
67
99
12
30
11
41
53
1
12
88
65
1
11
79
12
18
68
06
12
93
74
5
12
95
50
4
13
00
58
0
13
77
61
8
14
7
67
4
24
81
68
00
24
85
68
02
24
87
68
05
28
60
68
07
34
92
80
00
47
99
50
34
RA
TE
KDS ID
Performance Rate
Benchmark (0.8158)
*Data as of July 20, 2018 for Total Performance (October 2016 – December 2017)
MICAH – Post-Operative Sepsis (SEPSIS-1)
0
2
4
6
8
10
12
14
161
30
0
58
0
14
7
50
4
68
04
12
18
12
30
74
5
12
88
11
79
12
93
68
01
12
95
68
06
11
69
11
41
13
77
53
1
61
8
60
9
65
1
67
99
67
4
24
81
68
00
24
85
68
02
24
87
68
05
28
60
68
07
34
92
80
00
47
99
50
34
RA
TE
KDS ID
Performance Rate
Benchmark (1.855)
*Data as of July 20, 2018 for Total Performance (October 2016 – December 2017)
MICAH – Methicillin-resistant Staphylococcus aureus LabID Blood Event (MRSA-1)
0
1
2
3
4
5
6
7
8
67
99
11
69
53
1
68
06
68
01
12
18
11
41
12
30
11
79
60
9
65
1
12
88
68
04
12
93
74
5
12
95
50
4
13
00
58
0
13
77
61
8
14
7
67
4
24
81
68
00
24
85
68
02
24
87
68
05
28
60
68
07
34
92
80
00
47
99
50
34
RA
TE
KDS ID
Performance Rate
Benchmark (0.2417)
*Data as of July 20, 2018 for Total Performance (October 2016 – December 2017)
MICAH PFE Status
2830 30
33
20
0
5
10
15
20
25
30
35
PFE 1 - Planning ChecklistFully Implemented or No
Scheduled Admissions
PFE 2 - Shift Change HuddlesFully Implemented
PFE 3 - Responsible PartyFully Implemented
PFE 4 - PFAC/ Patientadvisor on QI TeamFully Implemented
PFE 5 - Governing BoardFully Implemented
PFE Status - MICAH Members
MICAH PFE Status
17
30 30
33
20
45 5
2
9
3
0 0 0
6
11
0 0 0 00
5
10
15
20
25
30
35
PFE 1 - Planning Checklist PFE 2 - Shift ChangeHuddles
PFE 3 - Responsible Party PFE 4 - PFAC/ Patientadvisor on QI Team
PFE 5 - Governing Board
PFE Status - MICAH Members
Fully Implemented Partially Implemented Not Implemented No scheduled admissions
GLPP HIIN Data Dashboard
PUBLIC Dashboard• Data will be blinded utilizing KDS ID
• Dashboard will shared in the near future
BCBSM PG5 P4P Updates
BCBSM PG5 CAH Current Benchmarks
Updated PG5 CAH Baselines
Updated PG5 CAH Baselines
Baselines are now 1 year in total and all 3 are the same
Updated PG5 CAH Baselines
Hospitals will be scored on
their numerators(incidents),
not their rate.
Updated PG5 CAH Baselines
Falls with Injury
For hospitals with Sustained Zeros in their Baseline they
will get an exception for 1 event.
Updated PG5 NON-CAH Baselines
P4P Storyboards – due by Nov. 1
2018-19 PG5 P4P Storyboard link
Upcoming Events
Opioid Safety Initiative for ED teams
The MHA Keystone Center, as part of the GLPP HIIN, will soon launch an opioid safety initiative for emergency department (ED) teams.
The project will replicate the Alternative to Opioids (ALTO) program, which was initially launched in Colorado and showed successful outcomes in reducing the
administration of opioids in EDs.
The MHA Keystone Center will host a launch meeting Sept. 11 at the MHA headquarters, Okemos. ED teams who are interested in participating should contact Brittany Bogan ([email protected]) at the MHA. Information about
initiative expectations and recommended team composition is available online.
2018 MHA Patient Safety & Quality Symposium
September 19, 2018
Ann Arbor Marriott Ypsilanti at Eagle Crest
2018 MHA Keystone Fall Workshop
October 23, 2018
JW Marriott, Grand Rapids
Register Now – Annual Symposium
Advancing Fall and Injury Prevention Practices Workshop
Wisconsin Hospital Association is hosting
virtual attendance for Michigan members
One-day conference
October 10
Featuring: Dr. Patricia Quigley
Registration Available
Fall and Injury Prevention Workshop
PSO Safe Table focused on workforce safety
October 16
VisTaTech Center, Livonia
Noon - 3 p.m.
Registration will open soon
MHA Keystone PSO Safe Table
Questions?
