Great. Thanks so much, Joan. It's really a pleasure to be here and share some of the work happening at Michigan and beyond. I've got no financial conflicts. I've lifted research funding here. Key roles are that I serve as the lead of a statewide sepsis consortium through the state of Michigan, which I'll be talking about today. And that work is funded by Blue Cross Blue Shield of Michigan. So I'll talk about this initiative. We work with 69 different hospitals. So we've learned a lot from all of our member hospitals about what are the things that they do to try to improve the implementation to give the very best delivery of the sort of basics or best practices for sepsis for each and every patient. So we'll talk about sort of what we've learned there. And then I'll share some resources to help with implementation perhaps at your hospital. So Hospital Medicine Safety, or HMS, this is a collaborative quality initiative. It's one of about 20 initiatives that are funded by Blue Cross Blue Shield of Michigan. I've listed them here. Most of these are surgical collaboratives. They focus on sort of high-cost areas for Blue Cross. But then Hospital Medicine focuses very broadly on the care of hospitalized medical patients. So Blue Cross funds these, but they believe that they have a good return on investment. By their own estimates have saved, you know, over a billion dollars as a result of complications avoided. So the operating model is that Blue Cross provides funding to a coordinating center, which is run out of University of Michigan. We serve as a data warehouse. We collect information from the member hospitals. We set performance targets. We facilitate quality improvement and convene meetings across all of our hospitals. And then the hospitals submit data into the statewide registry, receive performance reports, implement local quality improvement, and then share successes and challenges so that we can all kind of learn together. So 69 hospitals I mentioned participate. They're shown here. This is essentially all medium and large-sized hospitals throughout the state, as well as many of the smaller and critical access hospitals. And we've had five focuses over time since HMS was founded in 2010. And Sepsis is the newest initiative. Went live to all of our hospitals just in 2023. And I think everyone in this room knows why Sepsis is so important, but one of the questions is, well, how did Sepsis come to be a focus of HMS? Why did Blue Cross want to fund that? And it's an interesting story because Sepsis was actually a growing concern of Blue Cross because their customers, meaning large corporations that buy employer-based healthcare insurance like Auto Workers of America, were going to Blue Cross and saying, you know, we're looking at our data and Sepsis is common, we're seeing Sepsis is deadly, Sepsis is costly, and our employees who get Sepsis have trouble coming back to work. And so it was actually really these large corporations that were requesting that Blue Cross do more to address Sepsis in the state of Michigan. And so Blue Cross came to us and said, you know, we really think it would be important to have a Sepsis initiative. And now we do. So how do we identify Sepsis hospitalizations for our registry? So we identify it based on diagnostic coding, you know, people who have infection and may have Sepsis. Then we look into the actual charts. We have professional abstractors at each of the hospitals. And they look to see do they meet essentially CDC surveillance criteria of the adult Sepsis event definition. If they do, they get, you know, included into the registry. And then what are the things that we do, what are the things that we do to support quality improvement, implementation of best practices across our hospital? So using the registry, we do audit and feedbacks. We provide a quarterly report to each of our hospitals. How are they performing on Sepsis care and outcomes? We also have a live website that we launched this year. So our hospitals can actually look at their data in real time. We pull together tools and resources for all of our hospitals to use. So these are things like educational tools, documentation templates, order sets, protocols. We gather these from our hospitals and from beyond to share across our hospitals so we don't all have to be, you know, reinventing the wheel 69 times. We do networking. So we come together, all hospitals, three times a year. And then we have a performance index. So 30% based on participation, so timely and accurate submission of data into the registry and attendance at collaborative-wide meetings. And then 70% based on performance on performance measures for Sepsis and the other conditions. And this is tied to financial incentives. So essentially a multiplier on the RBU payments that hospitals get from Blue Cross. So a pretty strong incentive to participate and also to work to improve care. And then finally we do hospital visits. So doing like grand rounds presentations but also meet to discuss, you know, Sepsis policies, protocols at the hospitals and provide feedback. So in terms of things that we measure, we look broadly at structures, processes, and outcomes. Essentially the pillars of quality improvement. Structures we analyze through a biannual survey to our hospitals where we understand, you know, resources and what's happening. We understand processes from the data that is collected into the state registry. And so we have 30 processes of care approximately that we collect data on that are organized into four bundles. So early care in the first like six hours. Ongoing care that's kind of like the first two days. ICU to floor transition because we know transitions of care are traditionally a period of high risk or vulnerability to drop the ball. So we focus specifically there. And then peri-discharge management, setting our patients out for recovery, ensuring they have sort of follow-up. And then we collect outcomes through a variety of ways through chart abstraction, data linkages, and also directly calling our patients at 90 days to collect patient-reported outcomes. So these are some data from the onset to understand just how wide variation can be across hospitals. So this measure looks at antibiotics within three hours among people who present with hypotension. Each figure is a different hospital. And so collaborative wide average, 63% receive antibiotics within three hours if they show up to the emergency department with hypotension and meeting criteria for community onset sepsis. And then certainly you can see just wide variation across individual hospitals. Use of balance solutions over normal saline for resuscitation, wide variation there. And I would say overall low use of balance solutions at present in Michigan. But we are working on that. Provision of hospital contact, outpatient follow-up. Again, huge variation. And this seems to be more at the system level that some systems are set up to do this. But a lot of systems are still saying, oh, you know, we recommend follow-up, you know, go schedule that. And leaving that to the patient. So the CQI model for our other initiatives has had a really excellent track record of success. These are just some metrics on our other initiatives that have been running for many more years. And this is exactly the type of data that we are going to be collecting going forward on outcomes to try to understand and measure the impact that we are making as we work to improve sepsis care throughout Michigan. So I think key elements are that this has been clinician led. It's got robust data. We can set rigorous performance targets that aren't just sort of, you know, something we pull out of thin air. But are really informed by the distribution of what's actually happening on the ground. So that you're nudging hospitals forward each year. Not setting goals that are so impossible that people don't engage. Or, you know, setting targets that, you know, everyone's already doing that. So you don't really have to do anything more. I think the financial support is really helpful. So that even our low, like, resource hospitals. Everybody is actually getting payments from Blue Cross to fund the participation in this collaborative. And I think that's really important. There's also very strong incentives with the financial paper performance model for hospitals to engage. So in terms of at the individual hospitals, how are they able to move care forward? So here has been what a few things that we have learned are sort of key. First being leadership buy-in. The very, the leaders of the hospital understanding that sepsis is important. Sepsis accounts for about half of all hospital deaths. And signaling from the very high levels of the hospital to the clinicians about that being an institutional priority. That's really important. Investing in a program to improve care and outcomes of sepsis. Developing tools and resources to make it easiest to do the right thing, okay. Tracking and reporting progress over time. And then providing meaningful education on sepsis, particularly during the onboarding process. So what is happening on the ground in most hospitals? This is results from a morbidity and mortality weekly report that we did with CDC. This is questions from the national NHSN annual survey. It goes out to all hospitals. And for the first time in 2022, the survey asked about is there a committee at your hospital that addresses sepsis? And most hospitals have a committee, 73%. That sepsis is part of what they work on. But if you dig a little bit deeper, you find that actually only half of hospitals, or 55%, have any dedicated effort for people leading institutional work on sepsis. And again, this is a huge priority given half of all hospital deaths, you know, are related to sepsis. So I think that this suggests that there are opportunities for improvement. And so our Michigan Hospital Medicine Safety Consortium, we partnered with CDC over this past year, year and a half, to develop these hospital sepsis program core elements. And essentially, this is a user's guide of how do you build a program at your hospital to improve management and outcomes of sepsis. And so there is the guidance, a self-assessment tool for your hospital, and then also some infographics. And so this is really meant to complement existing guidelines, facilitate the implementation of those guidelines into practice, and really cover the full spectrum of hospitalization from sepsis recognition all the way out to discharge. And we also spent a lot of time trying to make this applicable to all hospitals in the U.S., regardless of the type or size of that hospital. So the core elements are hospital leadership commitment, accountability, which talks about having both leadership of the sepsis program, but also setting annual goals and reevaluating those annually. So actually having something that you are working towards that is objective and sort of codified. Multiprofessional expertise. I think we all know how important it is to have a multiprofessional sepsis team, given that sepsis can happen anywhere, and sort of spans all different departments in a hospital. Action refers to those structures, processes to support doing the right thing, the easiest thing. Tracking and reporting. Again, sort of having data to understand are you making a difference. And then education. We did a webinar series over the fall. These are all available online. There's five different webinars that go through in detail and have case presentations from different hospitals around the country sharing their work. And I'll just point out two of them. They're all excellent. But webinar one has the Michigan Medicine Hospital Sepsis Program. Jesse King and Pat Poza spoke. And they talk about how do you make a business case to your hospital to invest in the hospital sepsis program? How do you make the case that this will provide a return on investment? This question comes up all the time. And so I suggest this webinar. And then the second one is about the structures, processes. How do you make it easy to do the right thing? And we had two Henry Ford Health Hospitals. One talking about ED code sepsis, which is essentially a trigger to huddle at the patient bedside if they flag as potentially having sepsis. And these are just three-minute conversations. But it gets the whole care team on the right, on the same page. And they really sort of share how this didn't take a lot of resources to implement, but made a huge impact on being able to deliver the early elements of sepsis care. Getting antibiotics, getting fluid, getting these things started promptly. And then they also talk about discharge coordination. So those are both excellent. And then HMS, we launched a toolkit. This is publicly available online. I've given you the QR code. And this is really trying to be pulling together resources to help hospitals implement best practices for sepsis. We update this live. We have a email. So if you have feedback, you think this is good, this is bad, we're happy to take it. We're always trying to make this better, to make this the best possible resource for Michigan and beyond. And so this is organized around the CDC core elements. We've got a chapter on this hospital leadership commitment. We've got a number of chapters that focus on sort of the different bundles of processes that we focus on at HMS. And then we have a chapter related to quality improvement and implementation science techniques. So in conclusion, improving sepsis care requires a multi-pronged approach to these core elements. And also sort of continuous iteration to make sure that these structures and these processes are refined to, again, continually make it easier to do the right thing. So I will close there. And thank you all for your attention.

sepsis consortium

hospital collaboration

data-driven approach

performance reports

standardized care