Hospital Quality Improvement Project: Reducing Healthcare-Associated Infections Christine Martini-Bailey, RN, BSN Hospital Quality Project Lead

Debbie Nixon, PhD, MSHA, BSN Corporate Director

Presentation Outline • Introduce Health Services Advisory Group (HSAG), the Medicare Quality Innovation Network-Quality Improvement Organization (QIN-QIO) in California • Explore the business case for quality • Discuss the QIO Healthcare-Associated Infection (HAI) Prevention Collaborative • Introduce Targeted Assessment for Prevention (TAP) reports 2

About HSAG • Has been committed to improving quality of healthcare for more than 35 years • Provides quality expertise to those who deliver care and those who receive care • Engages healthcare providers, stakeholders, Medicare patients, families, and caregivers • Provides technical assistance, convenes learning and action networks, and analyzes data for improvement 3

Nearly 25 percent of the nation’s Medicare beneficiaries

U.S. Virgin Islands

HSAG is the Medicare QIN-QIO for Arizona, California, Florida, Ohio, and the U.S. Virgin Islands. 4

What is a QIN-QIO? • Funded by the Centers for Medicare & Medicaid Services (CMS) • Tasked with implementing the National Quality Strategy – – – – – –

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Make care safer Ensure patient and family engagement Support coordination of care Advocate for disease prevention Promote best practices of healthy living Make care affordable

Department of Health and Human Services

Centers for Medicare & Medicaid Services

Medicare QIN-QIO Framework

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QIN-QIO Goals Align With the CMS Quality Strategy

www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/Downloads/CMS-Quality-Strategy.pdf

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QIN-QIOs Coordinate with providers and communities on data-driven quality initiatives.

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Beneficiary and Family-Centered Care (BFCC) QIOs

Value, Incentives, and Quality Reporting (VIQR) Support Contractors

Field quality-of-care complaints and appeals.

Help providers report quality measure data.

A Business Case for Quality

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Business Case for Quality

8% at risk

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Hospital Value-Based Purchasing (HVBP) Program FY 2017 Standards: Safety Domain Achievement Threshold

Benchmark

Catheter-associated urinary tract infection

0.845

0.0000

CLABSI

Central line-associated blood stream infection

0.457

0.0000

C. difficile

Clostridium difficile infection (CDI)

0.750

0.0000

MRSA bacteremia

Methicillin-resistant Staphylococcus aureus bacteremia

0.799

0.0000

PSI-90

Complication/patient safety for selected indicators (composite)

0.777936

0.547889

SSI

Surgical site infection Colon Abdominal hysterectomy

0.751 0.698

0.0000 0.0000

Measure ID

Description

CAUTI

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HVBP Weights FY 2013

Clinical Process of Care

Patient Experience of Care

HVBP Weights FY 2014

HVBP Weights FY 2015

Outcome

Efficiency

30%

45%

HVBP Weights FY 2016

25% 10%

40%

20%

30%

30% 70%

25%

30%

25%

20%

HVBP Weights FY 2017

Safety

20%

25%

5%

25%

25%

CAUTI CLABSI CDI MRSA SSI PSI

The Exponential Cost of an Infection INFECTION: Vascular catheter-associated infection hospital-acquired condition (HAC)

One Infection = Three Penalties PENALTIES:

HAC

PSIs

Readmissions (This infection is associated with a 33 percent increase in the odds of being readmitted within 30 days.)

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Source: Readmissions Due to Hospital-Acquired Conditions (HACs): Multivariate Modeling and Under-coding Analyses Final Report, September 2012

QIO HAI Prevention Collaborative

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HAI Collaborative Focus Areas

CLABSI

CAUTI

CDI

VAE* *Ventilator-associated event

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Learning and Action Networks

HSAG’s approach is customized by hospital

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Webinars with subjectmatter experts

Tools

Peersharing calls

Best practices

Onsite assistance

National Healthcare Safety Network (NHSN) Database • No “confirmation” of submission – Annual payment update (APU) failures – Missing data

• QualityNet Provider Participation Reports do not give a complete picture 17

Don’t stress…HSAG offers NHSN support!

HSAG’s Participation Agreement Hospital

HSAG

• Commit to evidence-based practices.

• Review NHSN data for timeliness.

• Confer NHSN rights to share data with HSAG.

• Target and maximize value-based purchasing performance scores.

• Support unit-based quality improvement by integrating evidence-based safety practices into daily work of a clinical area.

• Analyze data utilizing the new Centers for Disease Control and Prevention (CDC) TAP reports. • Provide one-on-one technical assistance for: • HAI surveillance definitions • NHSN unit mapping • NHSN data validation • Root cause analyses on infection events

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Assistance Provided by HSAG

Educate Staff

Serve as a Resource

Assess Current Processes

Offer opportunities for Assist with Reporting Host Learning Events Peer-to-Peer Sharing 19

TAP Reports

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TAP Reports • NHSN data • Targets prevention efforts to the areas of greatest need • QIO has state-wide report capabilities to enable blinded facility benchmarking • Uses a metric called the cumulative Number of prevented attributable difference (CAD) infections needed in order to reach target prevention goal 21

TAP Reports… are available for different infections. • CLABSI • CAUTI • CDI

are customizable. • Facility-specific • System-wide Quarterly reports available within two to four weeks of the close of the CMS quarter deadline. 22

TAP Reports: Sample Facility Report Location Rank Ranked by highest to lowest CAD and assists you in identifying where to focus quality improvement efforts Event The number of infections CAD How many infections a unit must reduce to achieve target SIR SIR Observed/Expected Number of Pathogens Enables infection control professionals (ICPs) to identify pathogens 23

TAP Reports: Sample QIO Report Facility Rank How your facility ranks compared to other California facilities Facility CAD How many infections you need to reduce to achieve the target SIR Location Rank Where specific units rank in the hierarchy of infections Location CAD How many infections a specific unit needs to reduce to achieve the target SIR

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Source: National Healthcare Safety Network (NHSN), https://sdn7.cdc.gov/nhsn/validateUserSecureLogin.action

Questions? Mary Ellen Dalton, PhD, MBA, RN

President & Chief Executive Officer

[email protected]

Christine Martini-Bailey, RN, BSN

Project Lead, Hospital Quality

[email protected]

Debbie Nixon, PhD, MSHA, BSN

Corporate Director

[email protected]

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This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for California, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. CA-11SOW-C.1-04302015-01 26