Welcome

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• Qualis Health is one of the nation’s leading healthcare consulting organizations, partnering with our clients across the country to improve care for millions of Americans every day

• Serving as the Medicare Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for Idaho and Washington

• QIOs: the largest federal network dedicated to improving health quality at the community level

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Agenda • EQuIP: Aligning the work of partners • Reality: Role of the IP and needs assessment • Concept: 4 pillars of support • Goals: Proposed outcomes measures • Participation: Enrollment and expectations • Feedback: Questions, answers, suggestions

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Aligning Work • Department of Health, Critical Access Hospitals

• Department of Health, HAI Program

• Washington State Hospital Association

• Qualis Health

• APIC, Puget Sound and Inland Northwest Chapters

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IP Role in CAHs • Often appointed to the role with or without training • Often unprepared for role (and no role models) • High turn-over • Few internal resources available • Limited time for professional development • Often wears many hats (IP, Quality, Safety, Employee Health,

Risk Management, Educator, PRN staff) • Improvement in skills often not supported by administration • May lack computer skills • May not have access to literature and other resources • May be the only IC resource in the whole community (must

know IC relative to multiple settings)

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Needs Assessment • Survey of CAH IPs, September 2014

• 19 of 39 CAHs responded

• 63% of respondents are APIC members

• 95% indicated need for Infection Control Basics

• 16% reported, “I need it now!”

• 100% indicated need for training in Advanced Topics

• 37% reported, “I need it now!”

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Current Offerings Available • APIC:

• Epi 101 and 201 • Seattle, March 16-18, 2015 • In-person format, with 2 hours of online training available • 21 contact hours • Not specific to the CAH • $650, plus travel and accommodations

• Healthcare- Associated IP Training Critical Access Hospitals

• Webinar format, 8 hours • Seems to be a light version of APIC’s Epi 101 course • $1000

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Proposed Development Model

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Web-Based Education

• Basics and advanced – tailored to CAHs • Offered as live webinar or recorded • Core curriculum to quickly “stand up” a new IP • May be offered in-person

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Curriculum • Aligned with APIC’s Competency Domains

• Leadership • Technology • Performance Improvement and Implementation

Science • Infection Prevention and Control

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Curriculum • Aligned with CBIC’s Core Competencies

• Identification of infectious diseases • Use and interpretation of diagnostic tests • Antimicrobial stewardship • Surveillance and epidemiological investigations • Preventing and controlling infections • Employee health • Risk reduction • Program management • Education • Research

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Mentorship • Access to experienced IPs

• Discussion boards • Listserv • Email • Phone-a-friend • www.pugetsoundapic.org

• Support for questions following recorded webinars

• FAQs

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Collaborative Learning • Conference calls with CAH IPs

• Facilitated discussions on specific topics

• Optional cohort-supported implementation of evidence-based practice, with collaborative PDSAs

• Goal is to share successes, discuss barriers, learn from each other

• Develop network of CAH IPs for support

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Tools, Templates & Resources • Web-based repository of documents

available to CAH IPs • Templates • Sample policies • Assessment tools • Analysis tools • Reporting tools

• Adapted specifically for CAH setting • Customizable for use by CAHs

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Outcome Measures Proposed measures

• Establish baseline and ongoing rates of IP turnover in CAHs over 3 years

• Improve CAH IP self-assessed competency and confidence in role

• Reduce Lab-ID hospital onset C. difficile infections in CAHs

• Create a cohort of CAHs in Washington State to measure and benchmark HAIs

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Enrollment and Participation

• Participation Agreement

• Signed by hospital executive

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Enrollment and Participation

• Enrollment Form

• Hospital contact information

• Name and contact information of individuals participating

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Enrollment and Participation

• Competency and Confidence Self-Assessment • Likert scale:

• “Novice” • “Beginner” • “Competent” • “Proficient” • “Expert”

• Assess baseline needs • Complete annually for comparison • Evaluate program effectiveness • Based on APIC’s Competency Self-Assessment and Professional

Development Plan (2012)

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Enrollment and Participation • Qualis Health NHSN group

• Confers access rights to data

• Allows assistance with NHSN reporting

• Allows benchmarking of HAI data

• Reports are de-identified, aggregated, and confidential

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Courses • Learning Management System • Recorded PowerPoint or webinar • Course materials • Course quiz • Course evaluation • Certificate of completion • Course-related FAQs or discussion board

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Course Catalog • Program Management Basics

• Infection Prevention as a Program

• Risk Assessment and Prioritized Planning

• Infection Surveillance in the Critical Access Hospital

• Regulatory and Accreditation Requirements of an Infection Control Program

• Mandatory HAI Reporting in Critical Access Hospitals (Washington State)

• Conducting an Outbreak Investigation in the Critical Access Hospital

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Course Catalog

• NHSN Series • Getting started

• Data entry and submission

• Analysis and reporting

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Course Catalog • Foundational Courses

• Public Health, Communicable Diseases, and Infection Control in Rural Communities

• Microbiology 101

• Hand Hygiene: Measurement, Improvement, and Other Contemporary Issues

• Standard and Transmission-Based Precautions

• Cleaning and Disinfection in the CAH

• Disinfection and Sterilization in the CAH

• Assessing IC Risks in Construction and Renovation

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Course Catalog • Preventing HAIs (Bundle Basics)

• Catheter-Associated Urinary Tract Infections

• Central Line-Associated Blood Stream Infections

• Clostridium difficile Infections

• Surgical Site Infections

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Course Catalog • Deep Dives into Diseases

(Identifying and Controlling Infectious Diseases) • Tuberculosis

• Neisseria meningitidis

• Measles, mumps, rubella

• Viral Hepatitis B and C

• Influenza

• HIV/AIDS

• Diarrheal diseases

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Course Catalog

• Employee Health • Respiratory Protection Program in the CAH

• Immunization of Healthcare Personnel

• Minimizing Occupational Exposure to Blood-borne Pathogens

• Occupational Health in the CAH

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Course Catalog • Advanced Topics

• Evaluating Research

• Rates, Ratios, and Other Statistics

• Engaging Patients in Infection Prevention

• Plan-Do-Study-Act Cycles

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Program Management Basics

• March 16th – 8:00 AM to 4:30 PM

• Red Lion at the Park, Spokane • $25 registration fee (includes lunch) • To register: Jamie Moran or Kim Kelley http://app.certain.com/profile/form/index.cfm?PKformID=0x20004541d8d

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This material was prepared by Qualis Health, the Medicare Quality Innovation Network - Quality Improvement Organization (QIN-QIO) for Idaho and Washington, 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. WA-C1-QH-1623-02-15

Questions? Kim Kelley

CAH Program Manager Jamie Moran MSN, RN, CIC

Washington State Department of Health Kim.Kelley@doh.wa.gov

(360) 236-2807

QI Consultant, WA State JamieM@qualishealth.org

(206) 288-2512

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