Partnership for Patients Reporting Toolkit

Partnership for Patients (PfP) Hospital Engagement Network (HEN)

Iowa Healthcare Collaborative (IHC) Metric and Measurement Toolkit

May 2014 Version 4.0

http://www.ihconline.org

515.283.9330

Table of Contents

Introduction 3

Logon and Registration Screen 5

Welcome Screen 6

Metric Selection Screen 7

Data Entry Screen 8

Running Reports 9

Focus Area Metrics 10

Focus Area Measure Definitions 11

Readmissions (App I/App II) 11

Catheter-Associated Urinary Tract Infections (App III) 13

Central Line-Associated Bloodstream Infection (App VI) 15

Surgical Site Infections (App V) 17

Ventilator-Associated Events (App VI) 19

Adverse Drug Events (App VII) 21

Falls & Immobility 23

Pressure Ulcers (App VIII) 25

Obstetrical Adverse Events (App IX/X) 26

Venous Thromboembolism (App XI) 29

Safety Across the Board (GREEN) 30

Appendices 31

Appendix I 31

Appendix II 32

Appendix III 34

Appendix IV 36

Appendix V 37

Appendix VI 39

Appendix VII 40

Appendix VIII 41

Appendix IX 42

Appendix X 43

Appendix XI 44

Appendix XII 45

Introduction

In the first two years of the HEN, IHC and the Iowa Hospital Association built a web-based PfP HEN Reporting Database to track and monitor progress towards the 2014 PfP Aims, 40% reduction in Hospital-acquired Conditions and 20% reduction in readmissions (40/20/14). This PfP Reporting Database design supports the improvement work of the network hospitals and allows for hospitals to monitor trends in Process and Outcomes measures.

The Reporting Database allows identified hospital leadership (e.g. – Quality Improvement Advisor, Data Improvement Advisor) to securely/privately enter hospital performance metric data and quality improvement (QI) project data. Importantly, the database serves as a Quality Measurement and Reporting system (QMRS) for the HEN program. The database requires hospital staff to login and complete and update work plans for all 10 PfP focus areas. The work plan captures the project lead, clinical lead, physician lead, and front-line staff champion for all 10 focus areas. Also within the database, hospitals select the process and outcome metrics that are reported for the 10 PfP focus areas. Hospitals, along with support from their Improvement Advisor, continuously update the work plan throughout OY1 (Option Year 1) as interventions are implemented, goals are attained, and improvements are made to their focus area work. The database continuously captures the submission of monthly process and outcome measures for the focus areas.

The database is populated with monthly hospital-specific numerator/denominator information. In OY1, the HEN will use a three-pronged approach to expand reporting methodologies to include manual data entry, uploaded results of grouping methodologies applied to statewide database (SID) and data obtained from hospitals that confer rights of their data from CDC NHSN.

Hospital staff can access on-demand control charts after completing monthly data entry requirements. Results for each of the process and outcome metrics allow visual display that includes denominator results and a +1 standard deviation control. These control charts are a vital tool that can be shared during hospital team meetings to track and to drive clinical improvement efforts.

The Reporting Database allows IHC HEN Improvement Advisors and hospital HEN to accomplish a variety of project management functions. The database allows IHC to assist hospital project management designees in monitoring and tracking data management and improvement activities. The IHC staff utilizes the database reporting functions to communicate program performance to hospital leadership and designees. And, the IHC staff uses the database to support IHC HEN contract program management and reporting functions.

The IHC HEN has evaluated measurements that align with the national 40/20/14 goals. Historically, the IHC HEN encouraged the use of broad measures to generate the 40/20 reduction across the network. However, based on two years of learning, some of the measure populations currently being used by the IHC HEN are too narrow or not adequately defined. The evidence suggests that broader measures should be used to further our progress to the 40/20/14 goals. In order to align with national goals, the IHC HEN has proposed changes in the measures, specifically in outcome metrics.

Monthly data are due 45 days after the end of a month

·  Self-reported measures must be entered into the IHC PfP HEN data collection tool explained in this document.

·  Statewide database (SID – statewide inpatient database, SOD – statewide outpatient database) statistics will be aggregated each month with available information. Monthly control charts will be refreshed during an open quarter until verified quarterly data are ready. Hospital contacts are encouraged to work with inpatient/outpatient data submission personnel in their facilities in order to make results available in a timely manner.

·  NHSN metrics that are conferred to IHC and entered within 45 days after the end of a month will be downloaded for inclusion into control charts. Monthly control charts will be refreshed during any subsequent month.

Logon and Registration Screen

Log in using full email address as username and the secure password set up on registration. Password is cap sensitive.

A forgot password feature is available if necessary. Enter email address into the field designated, click on Send Password and current password will be automatically emailed to that address.

New users may register by following the New User Registration prompts. A confirmation email will alert user when access is confirmed.

To access the PfP Hen Reporting Tool go to:

http://pfp.ihconline.org/

Welcome Screen

The Welcome screen allows the user:

·  Access to select metrics for open months

·  Access for entry of data in open months

·  Informational messaging on monthly data entry status

·  Access to run/control charts

·  Access to the PfP Reporting Toolkit

·  Ability to open an Outlook episode for help on the program

Metric Selection Screen

Hospitals are required to report on at least 1 process and at least 1 outcome measure for each of the 10 focus areas that match their service delivery (e.g. – hospitals that do not deliver babies are excluded from the requirement to submit on OB Adverse Events). To select the metrics, each hospital will determine their options. Mark the checkbox to the left of the desired metrics. Choices will be continued in any subsequent month but changes to reporting options are available at any time.

For a list of the metrics see pages 10 – 23.

Navigation buttons at the top and bottom of the page include:

·  Save/Return Home – saves any changes and takes user back to the Welcome page

·  Save/Enter Data – saves any changes and takes user to the data entry page

·  Return Home – does not save changes and takes user to the Welcome page

Data Entry Screen

General rules applying to all metrics:

·  All facilities must select at least 1 process and at least 1 outcome measure per focus area

·  Interventions may be entered for each month in which they occur (NOTE: this information will appear on reports)

·  Fields are numeric only. Do not use decimals or characters

·  Edits will apply only upon selection of Complete Month

·  Discharges are reported in the month of the discharge date

Navigation buttons at the top and bottom of the page include:

·  Save Data – saves any changes and user remains on data entry page

·  Save Data/Return Home – saves any changes and takes user to the Welcome page

·  Run Edits – applies system edits against all fields and returns data entry problems

·  Complete Month – saves all changes, communicates that data entry is done for the month, runs edits and takes user to the Welcome page if no data issues are found. If edits are highlighted, they must be corrected in order to save data entered

Closing a month for data inclusion on monthly control charts

·  All data are due 45 days after the end of a month to be included in that month’s control charts

·  “Complete Month” must be selected and all edits corrected in order to be included in monthly control charts

Running Reports

Running Reports – Select View Run Charts on the Welcome page to generate hospital-specific report.

·  On-demand reports display monthly data points for completed months with 1 Standard Deviation control

·  Statewide comparative results are shown for quarterly verified data

·  Report questions or concerns to your Improvement Advisor if you have issues

Focus Area Metrics

The 10 focus areas include:

·  Readmissions

·  CAUTI (Catheter-Associated Urinary Tract Infections)

·  CLABSI (Central Line-Associated Bloodstream Infections)

·  SSI (Surgical Site Infections)

·  VAE (Ventilator-Associated Events)

·  Falls & Immobility

·  Pressure Ulcers

·  ADE (Adverse Drug Events)

·  VTE (Venous Thromboembolism)

·  Obstetrical Adverse Events

In an effort to minimize the reporting burden, additional data resources will be employed. For pages 10 – 23, color-coded metric definitions are explained:

·  BLUE – self-reported (monthly numerator and denominator entered into PfP HEN reporting tool),

·  GREEN – added from statewide databases (SID/SOD – inpatient and outpatient)

·  PURPLE – added from NHSN.

SELF-REPORTED
SID
NHSN

For metrics using the statewide databases, hospitals are encouraged to submit monthly data by 45 days after the end of each month. Point-in-time data results will be populated to each applicable area and data points will be displayed, if available, on the monthly control charts. During an open quarter, provisional results will be refreshed each month. Finalized, validated data points will provide comparative results for all participating HEN hospitals.

NHSN metrics must have hospital approval for use in HEN reporting by conferring rights at the measure level to IHC HEN to be included in control charts. Non-NHSN reporting hospitals or those who do not confer rights must enter the self-reported process and outcome numerator/denominator information where appropriate.

Focus Area Measure Definitions

Readmissions (App I)

Readmissions Process Measures: Self-Reported (BLUE)

SELF-REPORTED

1.  Observed interactions where teach-back is used by nurses per the number of observations

·  Numerator: Number of observations of nurses where teach-back is used to assess understanding

·  Denominator: Number of observations of nurse teaching

2.  Discharged patients with community providers included in post-discharge needs evaluation

·  Numerator: Number of patient discharges included in the denominator population where community providers (e.g. home care, primary care, nurses, skilled nursing) were included in assessing post discharge needs

·  Denominator: Number of discharges for acute care, skilled nursing care and swing bed patients in the sample

3.  Discharged patients with follow-up appointment scheduled before discharge

·  Numerator: Number of patient discharges included in the denominator population with follow-up appointment scheduled before discharge in accordance with risk assessment

·  Denominator: Number of discharges for acute care, skilled nursing care and swing bed patients in the sample

4.  Discharged patients where time critical information is shared appropriately

·  Numerator: Number of patient discharges included in the denominator population where critical information is transmitted to the next site of care (e.g. office, LTC, HH) or person continuing care

·  Denominator: Number of discharges for Acute Care, Skilled Nursing Care and Swing Bed patients in the sample

IHC HEN suggested resources:

·  APPENDIX I – STate Action on Avoidable Re-hospitalizations – STAAR model

http://www.ihi.org/offerings/Initiatives/PastStrategicInitiatives/STAAR/Pages/MeasuresResults.aspx

Readmissions Outcome Measures: Data from SID (GREEN)

SID

1.  Percent of unplanned all-cause, 30-day readmissions

·  Numerator: Number of patient discharges in the denominator population that meet criteria for inclusion as a readmission all-cause, 30-day methodology

·  Denominator: Number of discharges for Acute Care patients reported in the month of discharge date

IHC HEN suggested resources:

·  IHC HEN and subcontractor IHA developing strategy to provide monthly readmission rates

·  APPENDIX II – Hospital-Wide (All-Condition) 30-Day Readmission Measure - Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation. Measure developed in cooperation with the Wisconsin Hospital Association and adapted to display observed readmission rates. Details explained in Appendix II. http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/downloads/MMSHospital-WideAll-ConditionReadmissionRate.pdf

Catheter-Associated Urinary Tract Infections (App II)

CAUTI Process Measures: Self-Reported (BLUE)

SELF-REPORTED

1.  Unnecessary Urinary Catheters (Urinary catheters not meeting criteria for appropriate insertion)

·  Numerator: Number of patients in the denominator population with new indwelling urinary catheters inserted without appropriate indication documented at the time of insertion

·  Denominator: Number of patients with new indwelling urinary catheter insertions for Acute Care, Skilled Nursing Care, Swing Bed, and Observation patients

IHC HEN suggested resources:

·  APPENDIX III - Institute for Healthcare Improvement – IHI How-to Guide: Prevent Catheter-Associated Urinary Tract Infections, page 24 (Login required with free access to information)

·  http://www.ihi.org/knowledge/Pages/Tools/HowtoGuidePreventCatheterAssociatedUrinaryTractInfection.aspx

CAUTI Efficiency Measures: Data from NHSN or SID

1.  Rate of Urinary Catheter Utilization per Patient Day (Data from NHSN, PURPLE)

NHSN

·  Numerator: Number of indwelling catheter days (per NHSN definition)

·  Denominator: Number of patient days (per NHSN definition)

2.  Emergency Department Catheter Utilization (Data from SID, GREEN)

SID

·  Numerator: Number of indwelling urinary catheter placements in the Emergency Department

·  Denominator: Number of patients admitted to Acute Care, Skilled Nursing Care or Swing Bed status through the Emergency Department

IHC HEN suggested resources:

·  AMA CPT codes that will be utilized to identify catheters inserted in the Emergency Department:

·  51701

·  51702

·  51703

CAUTI Outcome Measure: Data from NHSN (PURPLE) or Self-Reported (BLUE)

SELF-REPORTED
NHSN

1.  Hospital-Acquired, Catheter-Associated UTI Rate per Catheter Day

·  Numerator: Number of hospital-acquired UTIs for patients in the denominator population per NHSN definition

·  Denominator: Number of urinary catheter days per NHSN definition

*report housewide or develop housewide reporting capability