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QSource Update: Reducing Hospital Infections

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QSource Update: Reducing Hospital Infections Manoj Jain, MD, MPH Medical Director, QSource 11 March, 2009 - Memphis 17 March, 2009 - Knoxville 26 March, 2009 - Nashville – PowerPoint PPT presentation

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Title: QSource Update: Reducing Hospital Infections


1
QSource Update Reducing Hospital Infections
Manoj Jain, MD, MPH Medical Director, QSource 11
March, 2009 - Memphis 17 March, 2009 -
Knoxville 26 March, 2009 - Nashville
2
Objectives for Today
  • Vision/Mission
  • Major Initiatives in TN by QIO and TN Center for
  • Patient Safety (TCPS) on MRSA/SCIP
  • QSource/TCPS MRSA/SCIP Crosswalk
  • Model for Change Within the MDRO Module
  • Other Present and Future Initiatives
  • Preparing for the Future

3
  • The right care
  • for every person,every time.

CMS Vision Statement for the National Healthcare
Quality Improvement Program
4
The Right Care
  • Safe
  • Timely
  • Effective
  • Efficient
  • Equitable
  • Patient-centered
  • The Institute of Medicine

5
MRSA and SCIP QSource and TCPS
Two Parallel, Overlapping, andSynergistic
Initiatives
  • History
  • Recruitment
  • Measures
  • Intervention
  • Evaluation

6
Historical Perspectives
  • Aug 2008 thru July 2011
  • 3 year timeframe
  • Funding from CMS through
  • QIOs
  • Clinical Advisors - Manoj
  • Jain, MD, MPH Marion
  • Kainer, MD
  • Team Leaders QSource
  • Patient Safety Team
  • Jan 2008 thru Jan 2010
  • 2 year timeframe
  • Funding from TN BC-BS
  • Health Foundation
  • thru THA TCPS
  • Clinical Advisors Peter
  • Pronovost, MD Chris
  • Goeschel Marion Kainer, MD
  • Team Leader - V/P and
  • Director TCPS

7
Recruitment Outcomes
  • MRSA
  • 63 Hospitals
  • SCIP
  • 69 Hospitals
  • MRSA
  • 30 Hospitals
  • SCIP
  • 22 Hospitals

8
SCIP Measure Comparisons
  • SCIP Inf-1 Antibiotic Administration within One
    Hour Before Incision
  • SCIP Inf-2 Use of Antimicrobial Recommended in
    Guideline
  • SCIP Inf-3 Antibiotic Discontinuation within 24
    Hours of Surgery End
  • SCIP Inf-4 Glucose Control in Cardiac Surgery
    Patients
  • SCIP Inf-6 Appropriate Hair Removal
  • SCIP-VTE-1 Recommended VTE Prophylaxis Ordered
  • SCIP-VTE-2 Received Appropriate VTE Prophylaxis
    within 24 Hours After Surgery
  • SCIP Inf-1 Antibiotic Administration within One
    Hour Before Incision
  • SCIP Inf-2 Use of Antimicrobial Recommended in
    Guideline
  • SCIP Inf-3 Antibiotic Discontinuation within 24
    Hours of Surgery End
  • SCIP Inf-4 Glucose Control in Cardiac Surgery
    Patients
  • SCIP Inf-6 Appropriate Hair Removal
  • SCIP Inf-7 Normothermia
  • SCIP-VTE-1 Recommended VTE Prophylaxis Ordered
  • SCIP-VTE-2 Received Appropriate VTE Prophylaxis
    within 24 Hours After Surgery

9
MRSA Measure Comparisons
  • MRSA-1 MRSA Infection Rate MRSA
    healthcare-associated infections that are not
    present or incubating on admission to the
    identified unit
  • MRSA-2 Hospital Onset MRSA Incidence Rate Based
    on Clinical Cultures a proxy measure of MRSA
    infections based on clinical cultures that have a
    hospital-onset
  • Required
  • of Admissions to Specific Unit During Reporting
    Period or Facility Wide
  • of Patient Days in Specific Unit During
    Reporting Period or Facility Wide
  • Hospital Onset MRSA (all cultures)
  • Optional Measures Also Reportable (See Crosswalk)

10
MRSA/SCIP Intervention Similarities
  • Intensive Approach
  • Onsite visits
  • Assistance with AHRQSurvey
  • Teach TeamSTEPPSMethodology
  • Conference Calls
  • Webinars
  • Broader Approach
  • Regional Workshops
  • Statewide Meetings
  • Monthly Conference Calls
  • Assistance with AHRQSurvey
  • Webinars

11
MRSA/SCIP Parallel Reporting Techniques
  • SCIP monthly throughTCPS Website
  • MRSA monthly throughMDRO Module
  • SCIP monthly throughTCPS Website
  • MRSA monthly throughTCPS Website

12
MRSA/SCIP Evaluation and Feedback Comparisons
  • Monthly data feedback with comparisons/benchmark
    s
  • Monitor closely andintervene as needed
  • Monthly data feedbackwith comparisons/benchmarks
  • Provide assistanceas requested

13
Summary of Parallel Initiatives
  • Collecting Many of the Same Measures
  • AHRQ Survey
  • Monthly Reporting of Measures
  • Conference Calls with Clinical Advisors
  • Monthly Feedback of Data with Benchmarking
    Data/Comparison to Other Collaborators

14
Health Research and Educational Trust (HRET)
  • Effort to Replicate Successes of Michigan
    Keystone Project Nationally
  • Conducting in Conjunction with American Hospital
    Association (AHA)
  • Comprehensive Unit-Based Safety Program (CUSP)
    Can Be Focused on Any Topic
  • To Pilot Soon in 10 States Through QIOs and State
    Hospital Associations
  • TN is Ahead of the Game Thanks to THA/TCPS!

15
MDRO Module Present CDC/CMSModel for Change
16
Key Elements of MDRO Module
  • Use of Module to Monitor at Least One
  • Inpatient Unit with High MRSA Rates
  • Enables Hospitals to Conduct MRSA
  • Infection Surveillance and Lab-ID Event
  • Reporting
  • Enables Hospitals to Collect Data on
  • Process Measures (Hand Washing, Barrier
  • Precautions, etc.)
  • Hospitals Can Also Choose to Collect
  • Data on CDAD

17
When MDRO Module goes Live
  • Statewide QSource Trainings in
  • Collaboration with Dr. Marion Kainer on the
  • Electronic Tool/Module
  • Tentatively Scheduled for April 2009
  • To be Held in 3 Cities Across the State
  • CMS Baseline Timeframe Began 2/1/09
  • Monthly Data Entry Expectation

18
Other QSource and TCPS Initiatives
  • QSource
  • Crossing the Continuum NH and Hospital Pressure
    Ulcer Project
  • Drug Safety Looking at Potentially
    Inappropriate Medications and Drug-to-Drug
    Interactions in Part D Data
  • TCPS
  • Central Line Blood Stream Infections (CLBSI)

19
Reporting Hospital Quality Data for Annual
Payment Update (RHQDAPU)
  • March 12th THA/QSource Webinar on the Release of
    the Dry Run Version of Hospital Specific Reports
    on AHRQ Measures
  • Latest HQA Preview Report for Discharge Quarters
    Q3 07 through Q2 08 Withholding Period Ended
    2/17/09 to go Live on Hospital Compare March
    2009

20
Next QSource Statewide Abstraction Clinic
  • March 19, 2009 from 900-1030 CST
  • To Highlight Changes to Q2/Q3 2009 Specifications
    Manual and Abstraction Guidelines

21
Why Do Some Hospitals Succeed?JAMA May 23/30,
2001 vol285, No 20
  • Shared Goals for Improvement
  • Substantial Administrative Support
  • Strong Physician Leadership
  • Credible Data Feedback

22
5 Strategies to Stay Off The List!
  • Prepare Know Your Numbers
  • Have a Team to Deploy/Assist with Efforts
  • Learn and Teach QI to All IP/Nurse Manager/
    Front Line Staff
  • Make a Business Case for Infection Prevention
  • Get Leadership Engaged and Boards on Board

23
What QI/IP Staff Need to Be Doing NOW
  • You are the Change Agent and Knowledge Base for
    Quality Improvement and Infection Prevention in
    Your Institution.
  • Culture Change/Work Together
  • Institute Concurrent Care Management
  • Standardize Infection Processes (Use Opt Out
    Approach for Order Sets)
  • Conduct Informal RCA of Cases that Fall Out
  • Engage Physicians
  • ASK Frontline Staff and Feedback Data Regularly

24
  • The right care
  • for every person,every time.

CMS Vision Statement for the National Healthcare
Quality Improvement Program
25
QSource Update Reducing Hospital Infections
Thank You!
Manoj Jain, MD, MPH Medical Director, QSource
This presentation and related materials were
developed by QSource, the Medicare Quality
Improvement Organization for Tennessee, under
contract with the Centers for Medicare Medicaid
Services (CMS), a division of the Department of
Health and Human Services. Contents do not
necessarily reflect CMS policy.
QSOURCE-TN-109.62-2008-15
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