QUALITY INITIATIVES: ROLE OF THE INFECTION...

QUALITY INITIATIVES:ROLE OF THE INFECTION

PREVENTIONIST

Evelyn Cook, RN, CIC

SPICE

October 17th, 2016

“Quality improvement is no longer a fringe philosophy in health care. Now mainstream approach for ensuring best possible care is delivered to every patient every day‐and it is rapidly taking its rightful place in the core business strategy for institutions trying to survive in an increasingly competitive marketplace”

Institute for Healthcare Improvement

WHAT IS HEALTH CARE QUALITY?

Every one has his/her definition of high quality health care Go to their doctor of choice

Receive any care they believe they need

Go to the hospital and not get an infection or suffer from some injury as a result of care

WHAT IS HEALTH CARE QUALITY?

Department of Health and Human Services (HHS) established the National Quality StrategyPriorities:

Better Care: patient‐centered, reliable, accessible

Healthy People/Healthy Communities: Support proven interventions

Affordable Care: Reduce the cost of quality health care for individuals, families, employers and government

Agency for Healthcare Research and Quality (AHRQ) defines quality health care:

“as doing the right thing for the right patient, at the right time, in the right way to achieve the best possible results”

INSTITUTE OF MEDICINE (IOM)Established in 1970 as a NGO (non‐government organization)

Works outside the framework of government to provide evidence‐based research and recommendations for public health and science

Patients must rely on health care professionals and institutions for their safety and well‐being. The IOM focuses on patient safety in order to promote policies and best practices that create safe and high‐quality health care environments.

On June 30th, 2015 became the National Academy of Medicine

IOM REPORTS

The Quality of Health Care in America Committee of the IOM

concluded that it is not acceptable for patients to be harmed by the

healthcare system that is supposed to offer healing and comfort– a

system that promises “first do no harm”

Released November 29, 1999

IOM REPORTS

Released March 1, 2001

“Between the health care that we now have and the healthcare that we could have lies not just a gap but a chasm”

IOM REPORTS

“Improving the diagnostic process is not only possible, but also represents a moral, professional, and public health imperative.”

Released September 2015

The committee concluded that most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences.

HEALTH CARE QUALITY ..INFECTION PREVENTION

QUALITY (IOM DEFINITION)

Safe: Patients should not be harmed by the care that is intended to help them.

Effective: Services based on scientific knowledge.

Patient‐Centered: Care that is respectful and responsive.

Timely: Reducing wait times and harmful delays

Efficient: Avoiding waste of supplies, resources

Equitable: No variation because of patient characteristics.

INFECTION PREVENTION Safe: Patients should not acquire a SSI as the result of a

surgical procedure

Effective: Femoral site should not be used for CL access; surgical prophylaxis appropriate and timely

Patient‐Centered: Patients on transmission based precautions should not receive a lower standard of care

Timely: Antibiotics should be administered as ordered

Efficient: Appropriate use of PPE; identification and disposal of regulated medical waste; antibiotic stewardship

Equitable: Foley catheters should not be placed solely due to patient incontinence

WHY QUALITY?CODE OF HAMMURABI, C. 1750 B.C

“If a physician make a large incision with the operating knife and kill him or open a tumor with the operating knife, and cut out the eye, his hands shall be cut off”

“If a physician make a large incision with an operating knife and cure it, or if he open a tumor (over the eye) with an operating knife, and saves the eye, he shall receive ten shekels in money “

WHY QUALITY?PRESENT TIME

Americans receive appropriate, evidence‐based care when they need it only 55% of the time

All Americans are at risk of receiving poor care (regardless of location, money, race, education)

As many as 91,000 Americans die each year due to lack of appropriate evidence based care

Per capita health spending varies by nearly two fold across geographic regions in the US; additional spending associated with NO improvement in quality/safety

The Essential Guide to Health care Quality NCQA

CEO Survival Guide: Pay 4 Performance 2006 Edition; National Committee for Quality Healthcare

Tens of thousands of Americans die each year as a result of preventable hospital errors

Condition What We Found Potentially Preventable complications or Deaths* (Annual)

Hypertension Less than 65% receivedindicated care

68,000 deaths

Heart Attacks 39‐55% did not receive needed medication

37, 000 deaths

Pneumonia 36% of elderly received no vaccine

10, 000 deaths

Colorectal Cancer 62% not screened 9, 600 deaths

1999 JAMA Report

INFECTION PREVENTION AND QUALITY

CDC

Up to 4 million inpatient HAI cases / year

90,000 deaths / year (at least 1/3 are preventable)

Hand HygieneAverage 40% compliance

HEALTHCARE ASSOCIATED INFECTIONS

It is estimated that more Americans die each year from HAIs than from auto accidents and homicides combined.

HAIs not only put the patient at risk, but also increase the days of hospitalization required for patients and add considerable health care costs.

HAIs are largely preventable through interventions:

Better hand hygiene

Compliance with policies and procedures

Advanced scientifically tested techniques for surgical patients.

McKibben L, Horan T Guidance on public reporting of healthcare-associated infections: recommendations of the Healthcare Infection Control Practices Advisory Committee. AJIC 2005;33:217-26.

WHY MEASURE PERFORMANCE?

There are many reasons why an organization should measure performance:Quality Improvement. Measuring performance can tell you what you’re doing well so you can share your successes and also reveal areas where you need to make adjustments. Measuring performance tells you whether you are achieving your ultimate goal of improving patient outcomes. Transparency. Stakeholders outside of the organization‐‐patients, funders, patient advocates‐‐want to know about the quality of care being provided. Patients want information that allows them to make informed choices about their health care services. Sharing performance information can also help an organization gain support and funding for its programs.

U.S. Department of Health and Human Services Health Resources and Services Administration

Accreditation. Organizations, such as NCQA, the Joint Commission, and the Accreditation Association for Ambulatory Health Care (AAAHC), evaluate health care provider organizations to provide accreditation or certification signifying that those places meet certain performance standards.

Participation in financial incentive programs or demonstrations.

Regulatory Compliance

Pay for Performance (Value‐based Purchasing)

DEMANDING QUALITY

Institute for Healthcare Improvement

Trial attorneys‐medical malpractice claims

Joint Commission sentinel event tracking

Consumers Union and other advocacy groups

Insurers: Pay for Performance

Industry: LeapFrog and other groups

Federal and State Goverments

HOW TO DETERMINE IP QUALITY PROJECTS AND INITIATIVES

Look at processes/procedures that are: High risk

High volume

Problem prone

New

HOW TO DETERMINE QUALITY PROJECTS AND INITIATIVES

Look at:

Quality monitors

Patient survey data

Employee comments

Risk management findings

Peer review information

Changes in the organization

DRIVERS OF QUALITY MEASUREMENT

Balancing financial and quality concerns

Increase public awareness of access, quality and cost

Demands for performance data

Expectations of improved, positive results

Institute of Healthcare Improvement (IHI)

100K Lives Campaign (prevent the 100,000 deaths in US over 2 years)

5 Million Lives Campaign (prevent 5 million lives from harm) –MRSA reduction is one of the major initiatives

QUALITY IMPROVEMENT METHODOLOGIES

Lean (Toyota Production System)

Six Sigma

FADE Focus, analyze, develop, execute, evaluate

PDSAPlan, do , study, act

DMAIC Define, measure, analyze, improve, control

DMADV Define, measure, analyze, design, verify

THE MODEL FOR IMPROVEMENT (IHI)

Simple yet powerful tool for accelerating improvement (not meant to replace facility change models but rather to accelerate improvement)

Two parts:

Three fundamental questions

PDSA Cycle

THE MODEL FOR IMPROVEMENT (IHI)

Steps:

Forming the Team

Setting Aims

Establishing Measures

Selecting Changes

Testing Change

Implementing Changes

Spreading Changes

QUALITY TOOLBOX TERMINOLOGY

Strategic Plan: Determines the direction an organization will go into the future and what

must be done.

Infection Prevention must have a detailed strategic plan

Performance Improvement Teams Project and or guidance teams


Gap Analysis What is?

What should be?

Identifying the “gaps” that exist

Root Cause Analysis Retrospective look at an adverse outcome

Determines what, why happened

Prevention techniques


Failure Mode Effect Analysis (FMEA), Proactive and preventive approach

Identify potential failures and opportunities for error

SWOT (strengths, weakness, opportunities, threats analysis)

MultivotingPrioritizing (IP risk assessment)

Goal‐Directed ChecklistVAP, CLABSI bundles

Charts, graphs and guidelinesIdentifies variation (special vs common cause)

Guidelines address reducing variation

CURRENT STATUS OF PERFORMANCE MEASURES

The JC

NHSN

CMS

SCIP

Individual States

Partnership for Patients

HHS Action Plan

WHAT AND HOW TO MEASURE?

Risk Potential

Sample Size

Method of Calculation and Reporting of Data

Risk‐Adjustment and Stratification

Data Elements and Collection

Interrater reliability

At least two raters could consistently classify the measure in the same way

TYPES OF MEASURESStructural: Measures the organization’s capacity and the conditions in which care is provided by looking at factors such as an organization’s staff, facilities, or health IT systems.

Example is ?

Outcome: result of performance or non‐performance of a functionExample is ?

Process: focuses on the steps in a process that lead to a specific outcomeExample is ?

U.S. Department of Health and Human Services Health Resources and Services Administration

EXAMPLES OF PERFORMANCE MEASURES:HHS ACTION PLAN

CLABSI: 50% reduction in ICU and wards

Central Line Bundle: 100% adherence

C. Diff: 30% reduction

CAUTI: 25% reduction

MRSA: 50% reduction

SSI: 25% reduction of admission and readmission

SCIP: 95% adherence

EXAMPLES OF PERFORMANCE MEASURES: PARTNERSHIP FOR PATIENTS: HENS

40% reduction in preventable hospital acquired conditions (1.8 million fewer injuries, 60,000 lives saved)

HAIs: CAUTI, CLABSI, SSI, VAP

20% reduction in avoidable readmissions

JOINT COMMISSION

Performance Improvement Standards

Infection Control Standards

National Patient Safety Goals – expanded focus for Infection Prevention

Hand Hygiene

CLABSI

MDROs

SSI

CAUTI

HEALTHCARE FACILITY HAI REPORTING TO CMS VIA NHSN:

Acute Care Hospitals

HAI Event Facility Type Start Date

CLABSIAcute Care Hospitals

Adult, Pediatric, and Neonatal ICUsJanuary 2011

CAUTIAcute Care Hospitals

Adult and Pediatric ICUsJanuary 2012

SSIAcute Care Hospitals

Colon and abdominal hysterectomy proceduresJanuary 2012

MRSA Bacteremia LabID Event Facility Wide Inpatient January 2013

C difficile LabID event Facility Wide Inpatient January 2013

HCP Influenza Vaccination All Inpatient HCP January 2013

Medicare Beneficiary Number All Medicare Patients Reported into NHSN July 2014

CLABSI Adult and Pediatric Medical, Surgical and Medical/Surgical Units January 2015

CAUTI Adult and Pediatric Medical, Surgical and Medical/Surgical Units January 2015

Long Term Hospitals (Long Term Acute Care Hospitals)

HAI Event Facility Type Start Date

CLABSI Adult, Pediatric, and Neonatal LTAC ICUs October 2012

CAUTI Adult, Pediatric, and Neonatal LTAC ICUs October 2012

HCP Influenza Vaccination All Inpatient HCP October 2014


C difficile LabID Event Facility Wide Inpatient January 2015

VAE Adult LTAC ICUs & Wards January 2016

Inpatient Rehabilitation Facility

CAUTI Adult and Pediatric IRF Ward October 2012



C. Difficile LabID Event Facility Wide Inpatient January 2015

Ambulatory Surgery Centers


STATES WITH MANDATORY REPORTING FOR HOSPITALS

QUALITY TOOLS USED BY INFECTION PREVENTION

Measurement tools include:Check sheet

Process flow charts:

Flow diagram; Fishbone

Run charts

Pie Charts

Histograms

Statistical process control charts

CENTRAL LINE INSERTION CHECKLIST/PI TOOL (Complete with all central line insertions: NOT A PART OF THE MEDICAL RECORD) Print extras in color or send to copy center

Patient Label

TUBE TO STATION 28 (Marketing) OR FAX TO 5370(INFECTION C ONTROL DEPT.)

Name of person completing form:_____________________

DATE Inserted: ________________ Unit/Location of patient at insertion ________________

NAME OF PERSON INSERTING CATHETER: ____________________________

Type of Catheter: PICC Central Venous Dialysis Pulmonary Artery

REASON FOR INSERTION: Emergent New indication Elective Replace malfunctioning catheterOther: __________________________

Right Left

INSERTION SITE Subclavian � �

PICC � �

IJ � �

Femoral � �

YES NO

CONSENT FORM SIGNED � �(except emergency)

PATIENT ID X 2 (Procedural Pause/Time out performed) � �

SITE MARKED � �

CONFIRM HAND HYGIENE PERFORMED � �

LARGE FULL BODY DRAPE USED � �

CAP, MASK, STERILE GOWN AND GLOVES WORN � �(For those placing and assisting with insertion of line)

MASKS ALL OTHER STAFF IN ROOM � �

PREP: CHLORAPREP APPLICATOR USED � �(30‐second scrub and 30‐ second dry time)

ULTRASOUND GUIDANCE USED

CHG Impregnated DRESSING USED � �

STERILE FIELD/TECHNIQUE MAINTAINED � �

HAND HYGIENE AFTER GLOVE REMOVAL � �

POSITION CONFIRMATION (fluoroscopy or CXR ordered)

USING GRAPHS AND CHARTS TO ILLUSTRATE QUANTITATIVE DATA

Graphs and charts condense large amounts of informationEasy to understand formats

Clearly and effectively communicate important points

A Picture is Worth a

Thousand Words!

FISHBONE DIAGRAM

Fishbone Diagram, Cause‐effect Diagram Identifies potential causes to the specific problem or breaks in a process

Organizes ideas in a clear manner

CAUTI

Foley CathTrays, kits

Nurses, techs, MD

ED, ICU Insertion technique

BAR CHARTS

One of the most common ways to visualize data

Easy to compare information and see highs and lows

When to Use: Comparing data across

categories

Answers “how many”0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

Rat

e p

er 1

00

0 P

atie

nt

Day

s

Hospital-acquired CAUTI1/1/2012-12/31/2012

HISTOGRAMS

A histogram is a specialized type of bar chart.

Individual data points are grouped together in classes, so that you can get an idea of how frequently data in each class occur in the data set.

A graphical representation of the distribution of data.

Persons infected with the outbreak strain of Salmonella Heidelberg, by week of

illness onset*

LINE CHARTS

One of the most frequently used chart types

Connect individual numeric data points

When to Use: Viewing trends in data over

time0

5

10

15

20

25

30

35

40

% M

RS

AYears

<200 beds 200-499 beds >500 beds

Percent MRSA Among S. aureusNosocomial Infections: 1975 - 1997

Source: National Nosocomial Infection Surveillance (NNIS) SystemSlide provided by Scott Fridkin, MD at CDC, HIP program

CONTROL CHARTS

The purpose of control charts is to allow simple detection of events that are indicative of actual process change.

If the process is in control (and the process statistic is normal), 99.7300% of all the points will fall between the control limits.

Any observations outside the limits, or systematic patterns within, suggest the introduction of a new source of variation, known as a special‐cause variation.

0

0.5

1

1.5

2

2.5

Jan-

11Fe

b-11

Mar

-11

Apr-

11M

ay-1

1Ju

n-11

Jul-1

1Au

g-11

Sep-

11O

ct-1

1N

ov-1

1D

ec-1

1Ja

n-12

Feb-

12M

ar-1

2Ap

r-12

May

-12

Jun-

12Ju

l-12

Aug-

12Se

p-12

Oct

-12

Nov

-12

Dec

-12

Rat

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CDI01/01/2011- 12/31/2012 (HO-HCFA and CO-HCFA)

95% CI Upper 90% CI Upper Mean

90% CI Lower 95% CI Lower Rate

PIE CHARTS

Should be used to show relative proportions‐or percentages‐of information

Most commonly mis‐used chart type

Pie charts are not the best for displaying information.

When To Use:

Showing proportions

Limit pie wedges to 6

OTHER TOOLS

Dashboards – Snapshot of current organizational statistics and trends, will ask for IC data – reported for hospital, department, unit, etc. – may go to Board of Trustees, Administration, etc.

Scorecards – Status check of progress of key strategic objectives or initiatives – often have graphics such as red light, yellow light or green light to quickly show where the organization “stands” on an indicator or measure

CONCLUSIONS

Obtain a baseline measure

Get the “right staff” involved

It is not just about the data; data integrity is vital

Choose the most appropriate tool for data presentation

Feed the data back to staff and all stakeholders

Quality Initiatives need to lead to improvement in patient care and patient outcomes

So No Matter What you call it ‐ Infection Prevention is an integral part of Quality

NEW QUALITY INITIATIVES – WHAT’S COMING

Mostly driven by CMS and Payment Issues:

Severity Adjusted DRGs

Present on Admission (POA) diagnosis

Increase in Public Reporting including infection rates

Quality improvements to include cost savings as well as improved patient care and outcomes

THOUGHTS TO PONDER

Numerator: the part of a common fraction appearing above the line, representing the number of parts of the whole that are being considered

“Five years ago this summer while under deep anesthesia for arm surgery # 3, I drifted above the line and joined the group called Numerators. I awoke with a HAI. Numerators are the most diverse group on Earth, our members include, every race, creed, every color…the old and the very young”

“Numerators have no organization, no colored ribbons, no walks and no marathons, our knights are few and far away. Our nightmare is devalued from disease to a “mere complication”, an event not even worthy of a simple apology……

Numerators don’t ask for much from the world. Our greatest dream is that you find the daily strength to truly care. To care enough to follow the checklists, to care enough to wash your hands, to care enough to only use virgin needles, for the saddest day for all Numerators is when another unsuspecting Denominator rises above the line to join us”

Remember… Infection Prevention Is In YOUR Hands

QUALITY INITIATIVES: ROLE OF THE INFECTION...

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