compass hiin toolkit

Compass HIIN Reporting Toolkit Version 1.0

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Compass Hospital Improvement

Innovation Network (HIIN)

Metric and Measurement Toolkit

Version 1.0

Updated November 4, 2016

This collaborative project was developed by: Iowa Healthcare Collaborative (IHC) and the Hospital

Improvement Innovation Network (HIIN)


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Contents Compass HIIN Data Reporting .............................................................................................................. 4

IHC HIIN Data Sources ........................................................................................................................ 4

Statewide Databases (IPOP)............................................................................................................ 4

National Safety Healthcare Network (NHSN) ................................................................................ 5

Self-Reported ...................................................................................................................................... 5

Sampling .............................................................................................................................................. 5

Reporting Deadlines ............................................................................................................................ 6

PfP Compass HIIN Reporting Database ......................................................................................... 7

Login and Registration Screen ......................................................................................................... 8

Open Month Management ................................................................................................................ 8

Metric Selection Screen .................................................................................................................... 9

Data Entry Screen ............................................................................................................................ 10

On-Demand Reports .......................................................................................................................... 11

Run Chart .......................................................................................................................................... 11

Goal Attainment Report ................................................................................................................... 13

CEO Dashboard ............................................................................................................................... 14

Core Focus Areas .................................................................................................................................. 16

Person and Family Engagement (PFE) ........................................................................................ 16

PFE Measures ................................................................................................................................. 16

PFE 1: ................................................................................................................................................ 16

PFE 2: ................................................................................................................................................ 17

PFE 3: ................................................................................................................................................ 18

PFE 4: ................................................................................................................................................ 18

PFE 5: ................................................................................................................................................ 19

Adverse Drug Events (ADE) ............................................................................................................ 21

Clostridium difficile ........................................................................................................................... 30

Catheter Associated Urinary Tract Infection (CAUTI) .............................................................. 36

Central Line Associated Blood Stream Infections (CLABSI) ................................................. 41

Falls and Immobility .......................................................................................................................... 45

Pressure Ulcers .................................................................................................................................. 54

Readmissions and Care Coordination ......................................................................................... 57


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Severe Sepsis and Septic Shock ................................................................................................... 65

Surgical Site Infection (SSI) ............................................................................................................ 70

Ventilator Associated Events (VAE).............................................................................................. 78

Venous Thromboembolism (VTE) .................................................................................................. 83

Additional Focus Areas (Optional) .................................................................................................... 88

Multi-drug Resistant Organism (MDRO) and Antimicrobial Stewardship ........................... 88

Hospital Culture of Safety (Worker Safety) ................................................................................. 92

Undue Exposure to Radiation ......................................................................................................... 96

Obstetrical Adverse Events ........................................................................................................... 100

ED Transfer Communication (MBQIP, for applicable facilities) ........................................... 106


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Compass HIIN Data Reporting During the Hospital Engagement Network (HEN), the Iowa Healthcare Collaborative (IHC) HEN

built a web-based Partnership for Patients (PfP) HEN Reporting Database (the Database) to

track and monitor progress toward the campaign PfP Aims. This PfP Reporting Database

design supported the improvement work of network hospitals and allowed hospitals to monitor

trends in Process and Outcomes measures.

Now in the Hospital Improvement Innovation Network (HIIN), the PfP Compass HIIN Reporting

Database will continue to allow identified HIIN network hospital leadership (e.g. – Quality

Director, Infection Preventionist, etc.) to securely and privately enter hospital performance

metric data and quality improvement (QI) project data. Importantly, the Database serves as a

Quality Measurement and Reporting System (QMRS) for the HIIN program. The Database can

be accessed, through secure login, by hospitals and Compass

The Database allows IAs and hospital HIIN program staff to accomplish a variety of project

management functions. The Database allows IHC, SDAHO and Telligen to assist hospital

project management designees in monitoring, tracking data management, and improvement

activities. HIIN program staff utilize the Database reporting functions to communicate program

performance to hospital leadership and to support Compass HIIN contract program

management and reporting functions.

Hospital staff can access on-demand run charts, goal attainment reports, and dashboards for all

measures after completing monthly data entry requirements. These reports are vital tools that

can be shared during hospital team meetings to track and to drive clinical improvement efforts.

Compass HIIN network hospitals are expected to:

Complete a work plan to begin reporting

Select from a menu of measures to comply with submission of at least one outcome and

one process measure for each focus area that applies to the hospital services

Confer NHSN rights for all applicable measures

Select from menu of optional focus areas (MDRO/Antimicrobial stewardship, Hospital

Worker Safety, and Undue Exposure to Radiation)

IHC HIIN Data Sources

Statewide Databases (IPOP)

Where available, IHC will process monthly data to return point-in-time monthly data points

utilizing available submitted information submitted on or around the 20th of each month. These

data will be grouped utilizing 1) the AHRQ (Agency for Healthcare Research and Quality)

Quality Indicator Grouping methodology, 2) existing relevant codes to identify records with ICD-

10 codes identifying numerators and 3) patient linking capabilities to identify readmissions.

Facilities where statewide databases are not accessible, see Self-Reported below.


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National Safety Healthcare Network (NHSN)

Hospital must confer rights for all applicable measures to the Iowa Healthcare Collaborative. On

or around the 20th of each month, IHC will download updated NHSN information for all HIIN

hospitals. These data are uploaded into the HIIN database for HIIN contacts to use for process

improvement.

Self-Reported

Measures requiring data mining/abstraction may utilize sampling methodologies. See

Improvement Advisors for options. Monthly data are due 45 days after the end of a month.

Access the Compass HIIN Reporting Database through a secure login to input hospital

information. Reports will immediately display updated information.

Sampling

Measurement should speed improvement, not slow it down. Often, organizations get bogged

down in measurement and delay making changes until they have collected all of the data they

believe they require. Remember, measurement is not the goal; improvement is the goal. In

order to move forward to the next step, a team needs just enough data to make a sensible

judgment as to next steps. Instead of measuring the entire process (e.g., all patients waiting in

the clinic during a month; all transfers from the ICU to the floor), measuring a sample (e.g.,

every sixth patient for one week; the next eight patients) is a simple, efficient way to help a team

understand how a system is performing. Sampling saves time and resources while accurately

Claim data submitted to state entity

Point-in-time data pulled

around 20th of each month

Data grouped and mined for

applicable measures

HIIN database refreshed

Run charts -Goal reports -

Dashboard report show

updated information

NHSN information submitted

Point-in-time data pulled around 20th of

each month

HIIN database refreshed

Run charts - Goal reports - Dashboard

report show updated information

Data mining and/or abstraction occurs internally

Data entry into HIIN Data Collection Tool

Run charts - Goal reports -Dashboard report

immediately display updated information


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tracking performance. The recommended sample size is 15-20% of the population you are

sampling. However, when you have a larger sample your data will be more valid and accurate

because it will represent your population appropriately.

Sampling has several primary purposes:

Provide a logical way of making statements about a larger group based on a smaller

group

Allow researchers to make inferences or generalize form the sample to the population if

the selection process has been random and systematic

Sampling Types:

Simple random sampling – The entire population has a chance of being selected. Ex.

Pulling a name out of a hat.

Systematic sampling – After picking the first patient, using every nth patient. Ex. Picking

every 5th patient.

Stratified random sampling – Picking a specific group or stratum from the population and

then randomly pick from that subpopulation. EX. Sex, diagnosis, department.

Cluster sampling – Divide the population into groups and then taking a random sample

for the group of interest. EX. Take all hospitals and divide them into individual hospitals

and then draw randomly from the individual hospital.

NAHQ Q Solutions Essential Resources for Healthcare Quality Professional, Information

Management RobertJ Rosati, PHD pg 41-42

Sampling Resource:

IHI Sampling

Directions for Systematic and Block Sampling

Reporting Deadlines Monthly data are due 45 days after the end of a month:

Self-reported measures must be entered into the data collection database explained in

this document.

Where available, the statewide database/claims data (SID - statewide inpatient

database, SOD - statewide outpatient database) will be utilized for populating select

measures.

o Hospital Quality leads/Primary HIIN contacts are encouraged to work with

inpatient/outpatient data submission personnel in their facilities to make results

available in a timely manner

http://www.ihi.org/resources/Pages/Tools/Sampling.aspx


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NHSN metrics that are conferred to IHC and entered within 45 days after the end of a

month will be downloaded for inclusion into the Database. Monthly reports will be

refreshed during any subsequent month.

Reporting Deadline 2016-2017

OCTOBER 2016 JUNE 2017

All reporting due December 15, 2016 60 Day CEO reminder sent out on January 1, 2017

All reporting due August 15, 2017 60 Day CEO reminder sent out on September 1, 2017

NOVEMBER 2016 JULY 2017

All reporting due January 15, 2017 60 Day CEO reminder sent out on February 1, 2017

All reporting due September 15, 2017 60 Day CEO reminder sent out on October 1, 2017

DECEMBER 2016 AUGUST 2017

All reporting due February 15, 2017 60 Day CEO reminder sent out on March 1, 2017

All reporting due October 15, 2017 60 Day CEO reminder sent out on November 1, 2017

JANUARY 2017 SEPTEMBER 2017

All reporting due March 15, 2017 60 Day CEO reminder sent out on April 1, 2017

All reporting due November 15, 2017 60 Day CEO reminder sent out on January 1, 2018

FEBRUARY 2017 OCTOBER 2017

All reporting due April 15, 2017 60 Day CEO reminder sent out on May 1, 2017

All reporting due December 15, 2018 60 Day CEO reminder sent out on January 1, 2018

MARCH 2017 NOVEMBER 2017

All reporting due May 15, 2017 60 Day CEO reminder sent out on June 1, 2017

All reporting due January 15, 2018 60 Day CEO reminder sent out on February 1, 2018

APRIL 2017 DECEMBER 2017

All reporting due June 15, 2017 60 Day CEO reminder sent out on July 1, 2017

All reporting due February 15, 2018 60 Day CEO reminder sent out on March 1, 201

MAY 2017 JANUARY 2018

All reporting due July 15, 2017 60 Day CEO reminder sent out on August 1, 2017

All reporting due March 15, 2018 60 Day CEO reminder sent out on April 1, 2018

MBQIP Reporting Deadlines

Q1 (January – March) – Due April 15

Q2 (April – June) – Due July 15

Q3 (July – September) – Due October 15

Q4 (October – December – Due January 15

PfP Compass HIIN Reporting Database Follow the narrative below for login and database navigation instructions.

First, click the following link to access the PfP HEN Reporting Database:

http://pfp.ihconline.org/




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Login and Registration Screen

Login using full email address as username and the secure password set up on registration.

Password is cap sensitive. Dual Authentication will be necessary for entry into the database.

This will occur each time the user logs in by the use of a “captcha” phrase.

A forgotten password feature is available if necessary. Enter email address into the field

designated, click on “Forgot Password” and current password will be automatically emailed to

that address.

New users may register by following the New User Registration prompts. All user registrations

must be approved by the system administration (Compass HIIN staff) prior to the user being

granted access to the database. A confirmation email will alert user when access is confirmed.

Open Month Management

The Open Month Management screen allows the user:

Access to select metrics for open months

Access for entry of data in open months

Informational messaging on monthly data entry status

Access to on-demand reports

Access to the Compass HIIN Reporting Toolkit

Link to contact IHC Helpdesk to request technical assistance


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See screenshot below:

Metric Selection Screen

Hospitals are required to report on at least one process and at least one outcome measure for

each of the focus areas (*with the exception of ADE and falls process measures) that match

their service delivery (e.g. – hospitals that do not care for ventilator patients are excluded from

the requirement to submit data on Ventilator Associated Events). To select the metrics, each

hospital will determine their options. Mark the checkbox to the left of the desired metrics.

Choices will be continued in any subsequent month but changes to reporting options are

available at any time.

*Hospitals must report on all ADE and Falls process measures.

Metric Selection - Navigation buttons at the top and bottom of the page include:

Save and Home – saves any changes and takes user back to the Welcome page

Save and Enter Data – saves any changes and takes user to the data entry page

Home – does not save changes and takes user to the Welcome page


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Data Entry Screen

General rules applying to all metrics:

All facilities must select at least one process and at least one outcome measure per

focus area, with the exception of ADE and falls process measures

Interventions may be entered for each month in which they occur (NOTE: this

information will appear on reports)

Fields are numeric only. Do not use decimals or characters

Please note that on PFE only a Yes/No choice is available

Edits will apply only upon selection of Complete Month

Discharges are reported in the month of the discharge date

Data Entry - Navigation buttons at the top and bottom of the page include:

Save Data – saves any changes and user remains on data entry page

Save Data/Return Home – saves any changes and takes user to the Welcome page


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Run Edits – applies system edits against all fields and returns data entry problems

Complete Month – saves all changes, communicates that data entry is done for the

month, runs edits and takes user to the Welcome page if no data issues are found. If

edits are highlighted, they must be corrected in order to save data entered

**Remember to save after each update. If the information is not saved, the user will be

prompted to save before leaving the page through a popup alert.

On-Demand Reports

Run Chart

Run or control charts are graphic displays of data points over time. Run charts are control charts

without the control limits.

Run charts available within the Compass HIIN Reporting Database are customizable allowing

users to add upper and lower control limits, add a trend line, and/or add data point labels to the

run chart. Users are able to run the report format as a pdf or export data into excel format to

allow for further customization and workability.


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Control limit: Control limits of your run chart represent your process variation and help

indicate when your process is out of control. Control limits are used to detect signals in

data that indicate that a process is not in control and, therefore, not operating

predictably. The upper and lower control limits are based on the variation in your facility

data.

Trend line: A line on a graph showing the general direction that a group of points seem

to be heading.


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Select “View Run Charts” on the Welcome page to generate hospital-specific report.

On-demand reports display monthly data points all reported months

Comparative results are displayed within run charts

For concerns or questions regarding data please contact your Improvement Advisor

Goal Attainment Report

Data are populated into the Goal reports from multiple sources (Statewide Databases (where

available), NHSN, or Self-reported). Hospital-level results are provided within this report to allow

users to determine facility performance.

Goal reports are customizable by measure and performance period and can be populated on-

demand by hospital quality staff from within the PfP Compass HIIN Reporting Database.

Goals reports contain baseline and performance data (including numerator and denominator

data) pertinent to the performance time frame specified by the user. Baseline periods included

within the goal reports are based on a 12-month time period. Performance period will be

populated as a 3-month time frame based on the performance end data selected by the user.

Within the Goal Report improvement percentages (i.e. percent changed from baseline period)

are calculated per measure.

*Please note that there may be blank cells on the Goal Reports. Blank cells indicate no data

were present in the timeframes designated for baseline and/or performance. If no data are

populated in the baseline and/or performance column(s), then the improvement column will also

be blank. Please contact your Improvement Advisor if cells are blank. They will assist with

identifying the reason for blank cells.

Goal Reports can be found on the reporting page along with other HIIN reports.


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CEO Dashboard

The CEO dashboard provides a “stoplight” view of current hospital progress toward HIIN goals.

Data are populated into CEO dashboard reports from multiple sources (Statewide Databases

(where available), NHSN, or Self-reported). In addition to hospital-level results, comparative

data are provided to allow users to determine facility performance compared to peer group,

Statewide averages and Compass HIIN network averages. Peer groups are divided by hospital

Medicare class and are combined into two groups: 1) Critical Access + Rural and 2) Rural

Referral + Urban.

Within the dashboard improvement percentages (i.e. percent changed from baseline period) are

calculated per measure. A positive number is an improvement, while a negative number

signifies a decline. Please keep in mind that the performance period is a moving target and

actual performance may change from month to month. CEO Dashboards are customizable by

measure and performance period and can be populated on-demand by hospital quality staff

from within the PfP Compass HIIN Reporting Database.

Breakdown of levels of achievement within the CEO Dashboard are as follows:

Red – <0%. No improvement, or performing below 0% improvement, or worsening for all

Healthcare Acquired Conditions (HACs) and Readmissions.

Yellow – 0 - 19% for all HACs. 0 - 11% for Readmissions. This means hospitals are maintaining

current level of improvement or showing progress toward goals but has not yet reached the

program goals. Hospitals that maintained a 0% improvement will be included in this category.

Green – 20% or greater for all HACs. 12% or greater for Readmissions. Hospital has met or is

exceeding the program goal.

*Please note that there may be blank cells on the CEO Dashboard. Blank cells indicate no data

were present in the timeframes designated for baseline and/or performance. If no data are


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populated in the baseline and/or performance column(s), then the improvement column will also

be blank. Please contact your Improvement Advisor if cells are blank. They will assist with

identifying the reason for blank cells.

CEO dashboards can be found on the reporting page along with other HIIN reports.


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Core Focus Areas Person and Family Engagement (PFE)

Previous HEN campaigns have built a solid foundation for Person and Family

Engagement (PFE), recognizing that partnering with patients and families is a critical

factor in achieving improvements in the quality and safety of care.

In HIIN, CMS continues to focus on PFE as a necessary component of improved quality

and safety. Five PFE metrics are included in monthly data collection. Hospitals will re-

evaluate their PFE status and make changes as necessary on a monthly basis.

Recommended PFE team members

Quality staff

Providers

Pharmacist

Department Managers/Directors

Frontline staff

Patient and Families

Health Coach

Social Worker/Case Manager

Doctor Office/Clinic Staff

Nursing Home

Home Care

PFE Measures

PFE 1:

Prior to scheduled admission, hospital staff provides and discusses a planning checklist

that is similar to CMS Discharge Planning Checklist with every patient, allowing time for

questions and comments from patient and family.

Tips and Tricks

Implementation of modified discharge checklist for use for all admissions

Utilize CMS Discharge Planning Checklist as a guide

Educate and ensure that information related to the importance of Patient and Family education is provided at new employee orientation and ongoing education throughout the year (Ex. Monthly staff meetings and competency/skill fairs)

PFE 1 Resources

AHRQ Strategy 4: Care Transitions from Hospital to Home - IDEAL Discharge Planning

Patient and Family as full partners in the discharge planning process. 5 key areas to prevent problems at home. Documents on Discharge Planning

http://www.ahrq.gov/professionals/systems/hospital/engagingfamilies/strategy4/index.html


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CMS Discharge Planning Checklist Sample of discharge planning with resources to consider

AHRQ Communicating to Improve Quality Documents to encourage patient participation in care

NAQC Fostering Successful Patient and Family Engagement: Nursing’s Critical Role What is patient engagement, why is patient engagement a nursing priority? Model and roadmap for nurse contribution to patient engagement

PFE 2:

Hospital conducts shift change huddles and does bedside reporting with patients and

family members in all feasible cases.

Tips and Tricks

Implement and maintain consistence of daily huddles

Implement and utilize huddle boards

Implement and review bedside report checklist

Utilize scripting for bedside reporting

Daily huddles should include: fall risk, Braden score, VTE prophylaxis, patients on warfarin, opioids or high risk medications, and expected discharge dates

Provide patient and family with information on bedside shift report to encourage participation

PFE 2 Resources AHRQ Strategy 3: Nurse Bedside Shift Report Bedside checklist, training and education

Bedside Shift Report Tools & Resources from Vanderbilt Medical Center Nursing Department Resources for bedside shift report and hourly rounding

AHRQ Nurse Bedside Shift Report Implementation Handbook Rationale, implantation and case studies for bedside shift report

AHRQ Nurse Bedside Shift Report Brochure Brochure for patient and family education

AHRQ Bedside Shift Report Checklist Checklist including SBAR

AHRQ Training PowerPoint

https://www.medicare.gov/Pubs/pdf/11376.pdf



http://www.ihconline.org/UserDocs/Pages/NAQC_PatientEngagement_WhitePaper.pdf



https://www.mc.vanderbilt.edu/sitebuilder/mcweb/web.php?site=vanderbiltnursing&doc=15927

https://www.mc.vanderbilt.edu/sitebuilder/mcweb/web.php?site=vanderbiltnursing&doc=15927

http://www.ihconline.org/UserDocs/Pages/Strat3_Implement_Hndbook_508.pdf

http://www.ihconline.org/UserDocs/Pages/Strat3_Tool_1_BSR_Broch_508.pdf

http://www.ihconline.org/UserDocs/Pages/Strat3_Tool_2_Nurse_Chklst_508.pdf


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Nurse bedside shift report training. Education on patient and family engagement, components of bedside shift report, HIPAA information and practice exercises

AHRQ Training PowerPoint - PDF Format

PFE 3:

Hospital has a dedicated person or functional area that is proactively responsible for

patient and family engagement and systematically evaluates patient and family

engagement activities.

Tips and Tricks

Create a staff liaison to develop the infrastructure for the patient and family advisors

Provide education and prepare hospital leadership

Create a patient and family advisory council or start with a short term project that involves patient and family advisors

PFE 3 Resources

AHRQ Working with Patient and Families as Advisors - Implementation Handbook

Resources include identifying a staff liaison, opportunities for PFAC, recruiting, selecting

and training

Patient and Family Advisor - Orientation Manual

Responsibilities, expectations, tips for being an engaged advisor

AHRQ Guide to Patient and Family Engagement in Hospital Quality and Safety

4 primary strategies for promoting patient/family engagement in hospital safety and

quality of care

Patient Engagement Who, What, Why

PFE 4:

Hospital has an active Patient and Family Engagement Committee or at least one

former patient that serves on a patient safety or quality improvement committee or

team.

Tips and Tricks

Utilize the below resources to invite and train patient and family advisors

PFE 4 Resources

http://www.ihconline.org/UserDocs/Pages/Strat3_Tool_3_Pres_video_508.pdf

http://www.ihconline.org/UserDocs/Pages/Strat1_Implement_Hndbook_508_v2.pdf

http://www.ihconline.org/UserDocs/Pages/Strat1_Tool_9_AdvisorTrain_508.pdf

http://www.ahrq.gov/professionals/systems/hospital/engagingfamilies/index.html?utm_medium=email&utm_source=govdelivery

http://www.ahrq.gov/professionals/systems/hospital/engagingfamilies/index.html?utm_medium=email&utm_source=govdelivery

http://www.health.state.mn.us/e-health/summit/summit2013/0302deering.pdf

http://www.health.state.mn.us/e-health/summit/summit2013/0302deering.pdf


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Pt and Family Advisor Tools:

AHRQ Patient and Family Advisor Application Form

Become a Patient and Family Advisor - Brochure

Am I Ready to Become an Advisor - Checklist

Confidentiality Statement for Advisors

Patient and Family Participation Interests

Do You Have Ideas to Help Improve our Hospital? - Postcard

Readiness to Partner with Patient and Family Advisors

Sample Letter of Invitation for Advisory Council Applicants

Sharing My Story: A Planning Worksheet

Working with Patient and Family Advisors

Working with Patient and Family Advisors on Short-Term Projects

Become a Patient and Family Advisor: Information Session

Working with Patient and Family Advisors: Introduction and Overview

Policy and Protocol Tools:

PFCC Go Shadow

Patient and Family Centered Care Methodology and Practice. Build care teams,

develop high-performance care teams, drive change and innovation

AHA Strategies for Leadership: Patient and Family Centered Care

Videos, resource guide and hospital self-assessment tool for Patient and family

centered care

Institute for Patient and Family Centered Care - Free resources

Strategies for Leadership, tools to foster the collaboration with patient and family

advisors and tools to assist in designing supportive health care environments

Advancing the Practice of Patient- and Family-Centered Care in Hospitals

Education on patient and family centered care, rationale, role of the leaders, selecting

preparing and supporting patient and family advisors and checklist for attitudes about

partnering with patients and families

Partnering with Patients and Families to Enhance Safety and Quality: A Mini Toolkit

Patient and family advisors vision, applications

PFE 5:

Hospital has at least one or more patients who serve on a governing or leadership

board and serves as a patient representative.

http://www.ihconline.org/UserDocs/Pages/Strat1_Tool_3_Application_508.pdf

http://www.ihconline.org/UserDocs/Pages/Strat1_Tool_1_Brochure_508.pdf

http://www.ihconline.org/UserDocs/Pages/Strat1_Tool_6_Checklist_508.pdf

http://www.ihconline.org/UserDocs/Pages/Strat1_Tool_10_PrvcyConfdn_508.pdf

http://www.ihconline.org/UserDocs/Pages/Strat1_Tool_8_PrtpntIntrsts_508.pdf

http://www.ihconline.org/UserDocs/Pages/Strat1_Tool_2_BecomeAdvisrPC_508.pdf

http://www.ihconline.org/UserDocs/Pages/Strat1_Tool_14_HO_508.pdf

http://www.ihconline.org/UserDocs/Pages/Strat1_Tool_4_Letters_508.pdf

http://www.ihconline.org/UserDocs/Pages/Strat1_Tool_7_Story_Hndout_508.pdf

http://www.ihconline.org/UserDocs/Pages/Strat1_Tool_12_WkWthAdv_HO_508.pdf

http://www.ihconline.org/UserDocs/Pages/Strat1_Tool_13_ShortTerm_HO_508-1.pdf

http://www.ihconline.org/UserDocs/Pages/Strat1_Tool_5_InfoSession_508.pdf

http://www.ihconline.org/UserDocs/Pages/Strat1_Tool_11_PPT_508.pdf

http://www.ihconline.org/UserDocs/Pages/Strat1_Tool_11_PPT_508.pdf

http://www.pfcc.org/go-shadow/

http://www.aha.org/advocacy-issues/quality/strategies-patientcentered.shtml

http://www.ipfcc.org/tools/downloads-tools.html

http://www.ipfcc.org/pdf/getting_started.pdf

http://www.ihconline.org/UserDocs/Pages/Patient_Safety_Toolkit.pdf


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Tips and Tricks

Create and implement the PFE Roadmap

Determine what the current hospital culture is regarding patient and family engagement

PFE 5 Resources

The Power of Having the Board on Board

6 crucial activities for boards

H2Pi Effecting Safety Across the Board Through Patient and Family Partnership

Councils for Quality and Safety (PEPCQS)

Tools, assessment of your organization, roadmap to success, strategic planning

Engaging Health Care Users: A Framework for Health Individuals and Communities

Guide

Strategies at the community, organization, health care team and individual levels

http://www.ihi.org/resources/pages/improvementstories/thepowerofhavingtheboardonboard.aspx

http://www.h2pi.org/index.html

http://www.h2pi.org/index.html

http://www.aha.org/research/cor/content/engaging_health_care_users.pdf

http://www.aha.org/research/cor/content/engaging_health_care_users.pdf


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Adverse Drug Events (ADE) An adverse drug event (ADE) is an injury resulting from the use of a drug. ADEs in hospitals can be caused by medication errors, such as accidental overdoses or providing a drug to the wrong patient, or by adverse drug reactions, such as allergic reactions or excessive bleeding after treatment with the intended dose of a drug that prevents dangerous blood clots. These measures look at the number of adverse drug events in the acute care, skilled nursing, swing bed, and observation units. In addition, these measures look at the number of lab measurements, blood glucose measurements, and electronically entered med orders in the inpatient setting. New pediatric measures have been added. See below for more detailed information about each measure. These measures help to determine how many and how often patients are harmed by ADEs.

Measures

Outcome Measures: Adverse Drug Event Rate

Numerator: Number of Acute Care, Skilled Nursing Facility, Swing Bed and Observation adverse drug events

Denominator: Number of Acute Care, Skilled Nursing Facility, Swing Bed and Observation patient days

Data Sources

Self-Reported

Recommended team members

Quality staff

Providers

Pharmacist


Frontline staff


Clinical IT

Tips and Tricks

Assemble an interdisciplinary team and develop an AIM statement that reflects organizational ADE goals


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Educate and ensure that ADE education is provided at new employee orientation

and ongoing education throughout the year (Ex. Monthly staff meetings and

competency/skill fairs)

Implement use of NCC MERP Scale Categories D-I for categorization of adverse

drug events

Utilize the NCC MERP algorithm

“0” denominator not allowed

Engage leadership on the importance of creating a just culture that allows front-line to feel empowered to fill out incidents reports when medication error occur

Provide Nursing education on ADE reporting and the importance of reporting near misses as well as reporting situations that cause harm

Resources

HRET Top Ten Checklist for ADE Top ten evidence based interventions for ADE

The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Medication Errors Definition, taxonomy and index for categorizing medication errors

NCC MERP Index for Categorizing Medication Errors Pie chart demonstrating medication errors categories A-I

NCC MERP Index for Categorizing Medication Error Algorithm Algorithm to categorize medication errors

University of Southern California School of Pharmacy Medication Therapy Intervention & Safety Documentation Program User Manual (v 7.0), pages 8-9. Adverse Drug Reaction (ADR) definition

Agency for Healthcare Research and Quality (AHRQ) H-CUPs Medication-Related Adverse Outcomes in U.S. Hospitals and EDs

Office of Disease Prevention and Health Promotion National Action Plan for Adverse Drug Event (ADE) Prevention H CUP Statistical Brief #109 Provides characteristics and medications most commonly involved in ADEs

http://www.hret-hen.org/topics/ade/13-14/2014-ADEChecklist508.pdf

http://www.nccmerp.org/

http://www.nccmerp.org/

http://www.nccmerp.org/sites/default/files/indexColor2001-06-12.pdf

http://www.nccmerp.org/sites/default/files/algorColor2001-06-12.pdf

http://www.ihconline.org/UserDocs/Pages/USC-Medication-Therapy-Intervention-and-Documentation-Manual--Updated-4-6-2012.pdf

http://www.hcup-us.ahrq.gov/reports/statbriefs/sb109.jsp

http://health.gov/hcq/ade.asp

https://www.hcup-us.ahrq.gov/reports/statbriefs/sb109.jsp


23

Adverse Drug Events Originating During Hospital Stay (AHRQ) Numerator: Number of Acute Care adverse drug events that cause harm

Denominator: Number of Acute Care, Skilled Nursing Facility and Swing Bed discharges

Data Sources

IPOP/Claims Data (where available)

Self-Reported


Quality staff

Providers

Pharmacist


Frontline staff


Clinical IT

HIM

Tips and Tricks

Assemble an interdisciplinary team and develop an aim statement that reflects your organization's ADE goals

Educate and ensure that ADE education is provided at new employee orientation



Ensure that your Pharmacist is communicating with coders to ensure proper

coding (applicable for claims data)


Provide Nursing education on ADE reporting and the importance of reporting near misses as well as reporting situations that cause harm

Resources

HRET Top Ten Checklist for ADE Top ten evidence based interventions for ADE University of Southern California School of Pharmacy Medication Therapy Intervention & Safety Documentation Program User Manual (v 7.0), pages 8-9. Adverse Drug Reaction (ADR) definition Agency for Healthcare Research and Quality (AHRQ) H-CUPs Medication-Related Adverse Outcomes in U.S. Hospitals and EDs

http://www.hret-hen.org/topics/ade/13-14/2014-ADEChecklist508.pdf

http://www.ihconline.org/UserDocs/Pages/USC-Medication-Therapy-Intervention-and-Documentation-Manual--Updated-4-6-2012.pdf

http://www.hcup-us.ahrq.gov/reports/statbriefs/sb109.jsp


24

Office of Disease Prevention and Health Promotion National Action Plan for Adverse Drug Event (ADE) Prevention Process Measures: *ADE Process measures for Blood Glucose, INR and Opioids are surrogate measures for measuring harm. These measures may include an Adverse Drug Event (ADE) or Potential Adverse Drug Event (pADE). It is critical that the HIIN team evaluate all data and assess level of harm according to the NCC-MERP scale.

Blood Glucose Less Than 50 Numerator: Number of blood glucose measurements (per lab reports, POCT, EMR, Charge Data, etc.) for Acute Care, Skilled Nursing Facility, Swing Bed and Observation patients where blood glucose <50

Denominator: Number of blood glucose measurements (per lab reports/POCT, EMR, Charge Data, etc.) for Acute Care, Skilled Nursing Care, Swing Bed and Observation patients

Data Sources

Self-Reported


Quality staff

Providers

Pharmacist


Frontline staff


Clinical IT

Physical/Occupational/Speech Therapy staff

Lab

Dietitian

Tips and Tricks


Exclude ED patients

Include Blood Glucose measurements less than 50 that occur only after patient is admitted to inpatient unit, exclude ER Blood Glucose Measurements less than 50

Include discussion of patients with hypoglycemia risk at your daily huddles and

individualize their interventions for safety

Include all lab results and blood glucometer readings

Implement the Basal Bolus Insulin Protocol

http://health.gov/hcq/ade.asp


25

Anticipate hypoglycemic events in patients with history of hypoglycemia

Educating diabetic patients and family members about symptom recognition of hypoglycemia

Develop a process to ensure that alternate methods are ordered for diabetes control if patient is unable to take their oral diabetes medication

Resources

Healthcare Communities

Basal Bolus Insulin Therapy – Inpatient Management

INRs Greater Than 5 Numerator: Number of lab measurements for Acute Care, Skilled Nursing Facility, Swing Bed and Observation patients on Warfarin where documented INR >5

Denominator: Number of INR lab measurements for Acute Care, Skilled Nursing Facility, Swing Bed and Observation patients on Warfarin

Data Sources

Self-Reported


Quality staff

Providers

Pharmacist


Frontline staff


Clinical IT

Nursing Home

Home Care

Respiratory/Therapy staff


Lab

Doctor office/Clinic staff

Tips and Tricks


Exclude ED patients Include discussion of patients with fall risk at your daily huddles and individualize

their interventions for safety


26

Support Pharmacy led warfarin management of inpatients

Small numbers and volumes can be hand collected

Ensure daily concurrent review of patients on warfarin by pharmacy

Weekly or monthly retrospective review of labs for patients on warfarin

Resources

Institute for Safe Medication Practices (ISMP) Improving Medication Safety with Anticoagulant

Stat Naloxone Administration Numerator: Number of episodes when a reversal agent (e.g. naloxone) is administered to Acute Care, Skilled Nursing Facility, Swing Bed and Observation patients prescribed opioids

Denominator: Number of Acute Care, Skilled Nursing Facility, Swing Bed and Observation patients prescribed opioids

Data Sources

Self-Reported


Quality staff

Providers

Pharmacist


Frontline staff


Health Coach


Clinical IT

Nursing Home

Home Care




Tips and Tricks

Exclude ED patients

Assess patient for opioid naïve or tolerance prior to administration of narcotics

Implement visual analog pain scale and conduct pain level assessment prior to initial dose and prior to subsequent doses of narcotics

http://www.ismp.org/tools/anticoagulanttherapy.asp


27

Develop a care plan step down treatment plan for decreasing and discontinuing narcotics

Resources

American Society for Pain Management American Society for Pain Management Nursing Guidelines on Monitoring for Opioid-Induced Sedation and Respiratory Depression

Opioid Therapy Treatment Plan Numerator: Number of patients discharged from a hospital on an opioid with patient-specific goals of therapy at discharge

Denominator: Number of patients discharged on opioids

Data Sources

Self-Reported


Quality staff

Providers

Pharmacist


Frontline staff


Health Coach


Clinical IT

Nursing Home

Home Care



Tips and Tricks

Exclude ED patients

Administer 1st dose of opioid prior to discharge

Assess patient for opioid naïve or tolerance prior to administration of opioids

Implement visual analog pain scale and conduct pain level assessment prior to initial dose and prior to subsequent doses of opioids

Develop a care plan step down treatment plan for decreasing and discontinuing opioids

Request that IT builds the treatment plan into EHR

Involvement of pharmacist in the treatment plan is favorable

http://www.aspmn.org/documents/GuidelinesonMonitoringforOpioid-InducedSedationandRespiratoryDepression.pdf


28

Resources

CDC Guideline for Prescribing Opioids for Chronic Pain

The guideline addresses: when to initiate or continue opioids for chronic pain, opioid selection, dosage, duration, follow-up, and discontinuation and assessing risk and addressing harms of opioid use

Use of Opioids for the Treatment of Chronic Pain

The American Academy of Pain Medicine offers statements on the use of opioids for the treatment of chronic pain

Utah Clinical Guidelines on Prescribing Opioids for treatment of Pain

Opioid treatment recommendations for acute and chronic pain. How to establish treatment goals and a written treatment plan. Initiating, monitoring and discontinuing opioid treatment. Documentation for EHRs

Utah Treatment Plan Using Prescription Opioids

Patient and prescriber treatment plan

Opioids911-Safety

Examples of treatment plans and pain management agreements

Prevalence of Naloxone Usage in Community Setting Prior to Admission Numerator: Number of patients who received naloxone in community setting prior to admission (Include ambulance, in-home, and law enforcement use of Naloxone)

Denominator: Number of Acute Care admissions

Data Sources

Self-Reported


Quality staff

Providers

Pharmacist


Frontline staff


Health Coach


Clinical IT

http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm

http://www.painmed.org/files/use-of-opioids-for-the-treatment-of-chronic-pain.pdf

http://www.azcjc.gov/acjc.web/rx/opioidguidelines_utahrecswithrationalesonly.pdf

http://health.utah.gov/prescription/pdf/guidelines/treatment_plan.pdf

http://arkham.bsd.uchicago.edu/GmedIntranet/documents/Op911-OpioidRxAgreements.doc


29

HIM

Nursing Home



Local EMS

Local Law Enforcement

Tips and Tricks

Request that IT builds the treatment plan into EHR

Collaborate with your local EMS and Law Enforcement

Provide education of naloxone usage for patients and families

Resources

Substance Abuse and Mental Health Services Administration - Opioid Overdose Toolkit

Includes facts for community members, prescribers and safety advice for patients and family members

CDC Opioid Overdose Prevention Programs Providing Naloxone to Laypersons – United State, 2014

Provides information on organizations that provide naloxone kits to laypersons

https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6423a2.htm

https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6423a2.htm


30

Clostridium difficile Clostridium difficile (C.diff) is a bacterium that causes infections within the digestive system. Measures focus on hospital-acquired C.diff and hand hygiene compliance, looking at hand washing technique. See below for more detailed information about each measure. The current NHSN Manual – Patient Safety Component is utilized for defining and reporting on these measures. To access the manual, follow this link: http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf. These measures will help to determine how many and how often patients are harmed by C.diff.

Measures

Outcome Measures:

Healthcare facility-onset Clostridium difficile Infection Rate

Numerator: Number of healthcare facility-onset Clostridium difficile infections

Denominator: Number of acute care inpatient days

Data Sources

NHSN


Quality staff

Infection Preventionist

Providers

Pharmacist


Frontline staff


Health Coach


Nursing Home

Home Care

Hospice

Lab


Dietitian

http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf


31

Tips and Tricks

Assemble an interdisciplinary team and develop an aim statement that reflects your organization's C diff goals

Educate and ensure that C diff prevention and handwashing education is

provided at new employee orientation and ongoing education throughout the year

(Ex. Monthly staff meetings and competency/skill fairs)

Participate in the HAI Community of Practice events

Confer NHSN rights to IHC

Develop and implement an Antimicrobial Stewardship Program

Ensure that all doctors, nurses, and other health care providers clean their hands with soap and water or an alcohol-based hand rub before and after caring for patients

Placement of Alcohol-based Hand Hygiene Dispensers to Increase Visitor Use

Select antimicrobials associated with a lower risk of CDI when possible and avoid antimicrobial exposure if patients do not have a condition for which antimicrobials are indicated

Ensure a physician leader dedicates a portion of their time to the design, implementation and function of an antimicrobial stewardship program and is accountable for the program’s outcomes

Provide Clostridium diff infection information for patients

Develop and implement appropriate protocols for sporicidal chemical sterilization of equipment and the environment

Ensure that personnel responsible for environmental cleaning and disinfection have been appropriately trained and are using the correct personal protective equipment

Ensure that Pharmacists conduct a daily review of targeted antimicrobials for appropriateness and contact prescribers with recommendations for alternative therapy

Resources

HRET Top Ten Checklist for CDI Checklist to review current or initiate new interventions for CDI prevention Clostridium difficile (CDI) Infections Toolkit Healthcare-association infection elimination PowerPoint from the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention CDC MDRO and CDI Module NHSN Multi drug resistant organism & clostridium difficile infection Module FAQs about Clostridium difficile (CDC) Fact sheet for patients to have as a resource when they are discharged

http://www.hret-hen.org/topics/cdi/HRETHEN_CheckList_CDI.pdf

http://www.cdc.gov/hai/pdfs/toolkits/CDI-Primer-2-2016.pdf

http://www.cdc.gov/nhsn/pdfs/pscmanual/12pscmdro_cdadcurrent.pdf

http://www.cdc.gov/HAI/pdfs/cdiff/Cdiff_tagged.pdf


32

Clostridium difficile Prevalence

Numerator: Number of Clostridium difficile Lab ID events

Denominator: Number of acute care inpatient admissions

Data Sources

NHSN


Quality staff


Providers

Pharmacist


Frontline staff


Health Coach


Nursing Home

Home Care

Hospice

Lab


Dietitian

Tips and Tricks

Assemble an interdisciplinary team and develop an aim statement that reflects your organization's ADE goals

Assemble an interdisciplinary team and develop an aim statement that reflects your organization's C diff goals

Educate and ensure that C diff education is provided at new employee

orientation and ongoing education throughout the year (Ex. Monthly staff

meetings and competency/skill fairs)

Participate in the HAI Community of Practice

Ensure your rights are conferred in NHSN to IHC

Antimicrobial Stewardship Programs in Health Care Systems

Ensure that all doctors, nurses, and other health care providers clean their hands with soap and water or an alcohol-based hand rub before and after caring for patients

Placement of Alcohol-based Hand Hygiene Dispensers to Increase Visitor Use


33

Select antimicrobials associated with a lower risk of CDI when possible and avoid antimicrobial exposure if patients do not have a condition for which antimicrobials are indicated

Ensure a physician leader dedicates a portion of their time to the design, implementation and function of an antimicrobial stewardship program and is accountable for the program’s outcomes

Provide Clostridium diff infection information for patients

Develop and implement appropriate protocols for sporicidal chemical sterilization of equipment and the environment

Ensure that personnel responsible for environmental cleaning and disinfection have been appropriately trained and are using the correct personal protective equipment

Ensure that Pharmacists conduct a daily review of targeted antimicrobials for appropriateness and contact prescribers with recommendations for alternative therapy

Maintain same number of sample audits each month to truly capture improvement and consistent trending

Resources

HRET Top Ten Checklist for CDI Checklist to review current or initiate new interventions for CDI prevention Clostridium difficile (CDI) Infections Toolkit Healthcare-association infection elimination PowerPoint from the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention CDC MDRO and CDI Module NHSN Multi drug resistant organism & clostridium difficile infection Module FAQs about Clostridium difficile (CDC) Fact sheet for patients to have as a resource when they are discharged

Clostridium difficile SIRs (Standardized Infection Ratio) will be obtained from NHSN information conferred to IHC and included in the analysis of statewide and national results for each eligible facility and all reported units

Process Measures:

Hand Hygiene Compliance Numerator: Number of observations where appropriate hand-washing technique was applied

Denominator: Number of observations

http://www.hret-hen.org/topics/cdi/HRETHEN_CheckList_CDI.pdf

http://www.cdc.gov/hai/pdfs/toolkits/CDI-Primer-2-2016.pdf


http://www.cdc.gov/HAI/pdfs/cdiff/Cdiff_tagged.pdf


34

Data Sources

Self-Reported


Quality staff


Providers

Pharmacist


Frontline staff


Health Coach


Tips and Tricks

Educate and ensure that handwashing education is provided at new employee



Provide demonstration and live validation to ensure method of handwashing is effective

Utilize a standard form that everyone uses for observations, include all staff that have patient interaction

Resources

CDC Hand Hygiene in Healthcare Settings Hand hygiene basics, training, guidelines and measurement Hand Hygiene Observation Record This form can be used when performing hand hygiene observations

Institute for Healthcare Improvement How-to Guide: Improving Hand Hygiene (this is a free resource, sign into IHI to download) interventions for improved handwashing, measurement tools World Health Organization (WHO) Clean Care is Safer Care – Hand Hygiene Tools and Resources WHO Guidelines on Hand Hygiene in Health Care Your 5 Moments for Hand Hygiene – Poster

Contact Precaution Compliance

Numerator: Number of contact precautions performed consistent with guidelines

Denominator: Number of observations

http://www.cdc.gov/handhygiene/

http://www.ihconline.org/UserDocs/Hand_Hygiene_Observation_Template.pdf

http://www.ihi.org/resources/pages/tools/howtoguideimprovinghandhygiene.aspx

http://www.who.int/gpsc/5may/tools/en/

http://www.who.int/gpsc/5may/tools/who_guidelines-handhygiene_summary.pdf

http://www.ihconline.org/UserDocs/Your_5_Moments_For_Hand_Hygiene_Poster.pdf


35

Data Sources

Self-Reported


Quality staff


Providers

Pharmacist


Frontline staff




Lab

Tips and Tricks Educate and ensure that Contact Precaution education is provided at new

employee orientation and ongoing education throughout the year (Ex. Monthly

staff meetings and competency/skill fairs)

Provide demonstration and live validation to ensure method of contact isolation is effective

Utilize a standard form that everyone uses for observations

Ensure availability of gloves, gowns, masks and other protective items

Resources

CDC Basic Infection Control and Prevention Plan for Outpatient Oncology Settings

Please see “B” Contact Precautions, includes conditions and disease to consider when using contact precautions, types of protection and patient education

CDC Precautions to Prevent Spread of MRSA Information on standard and contact precautions

Hand Hygiene/Contact Precautions Monitoring Tool

This form can be used when performing contact precautions observations

http://www.cdc.gov/HAI/settings/outpatient/basic-infection-control-prevention-plan-2011/transmission-based-precautions.html

http://www.cdc.gov/mrsa/healthcare/clinicians/precautions.html

https://www.mnhospitals.org/Portals/0/Documents/ptsafety/ControllingCDI/5a_Controlling%20CDI%20-%20%20United%20Hospital%20Hand%20Hygiene%20AuditingTool.pdf


36

Catheter Associated Urinary Tract Infection (CAUTI) A Catheter-associated Urinary Tract Infection (CAUTI) is a serious infection that occurs when bacteria enter the body through a urinary catheter.

These measures look at catheter utilization in inpatient settings and within the emergency department. The Outcome measure focuses on the number of hospital-acquired urinary tract infections that occur. See below for more detailed information about each measure. The current NHSN Manual – Patient Safety Component is utilized for defining and reporting on these measures. To access the manual, follow this link: http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf. These measures help to determine how many patients are harmed by CAUTIs.

Measures Outcome Measures: Catheter-Associated Urinary Tract Infection Rate

Numerator: Number of hospital-acquired urinary tract infections

Denominator: Number of Acute Care urinary catheter days

Data Sources

NHSN


Quality staff


Providers


Frontline staff


Tips and Tricks

Assemble an interdisciplinary team and develop an aim statement that reflects your organization's CAUTI goals

Educate and ensure that CAUTI education is provided at new employee orientation



Participate in the HAI community of practice

Include discussion of patients with foley catheters in place at your daily huddles and the possibility to remove the foley catheter



37

Confer rights to IHC in NHSN

Request that IT build the acceptable indications for inserting an indwelling catheter into your EHR. Ensure this is on your provider’s screen so they can choose an indication

Implement a system for documenting the following in the patient record: physician order for catheter placement, indications for catheter insertion, date and time of catheter insertion, name of individual who inserted catheter, nursing documentation of placement, daily presence of a catheter and maintenance care tasks, and date and time of catheter removal

Educate patients and families about CAUTIs are and how they can be prevented

Assemble a team to address cultural barriers to CAUTI prevention using the comprehensive unit-based safety program (CUSP)

Resources

HRET Top Ten Checklist for CAUTI Top 10 evidence based interventions

CDC Device-associated Module – CAUTI Urinary Tract Infection (Catheter-Associated Urinary Tract Infection [CAUTI] and Non-Catheter-Associated Urinary Tract Infection [UTI]) and Other Urinary System Infection [USI] Events, Criteria and SIRs

CDC HICPAC CAUTI Guidelines, Strategies for prevention of CAUTI, CAUTI Surveillance

Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals Highlights practical recommendations in a concise format to assist acute care hospitals in implementing catheter-associated urinary tract infection prevention efforts and provides recommendations for surveillance

NHSN Urinary Tract Infection Form This form expires 12/31/2017 *CAUTI SIR (Standardized Infection Ratios) will be obtained from NHSN information

conferred to IHC and included in the analysis of Compass HIIN network and national

results for each eligible facility and reported for two cohorts – one for ICUs and another

for ICUs with Other Reporting Units.

Process Measures:

Unnecessary Urinary Catheters

http://www.hret-hen.org/topics/cauti/13-14/2014-CAUTIChecklistUpdate.pdf

http://www.cdc.gov/nhsn/PDFs/pscManual/7pscCAUTIcurrent.pdf

http://www.cdc.gov/hicpac/CAUTI_fastfacts.html

http://www.journals.uchicago.edu/doi/full/10.1086/591066?cookieSet=1

http://www.journals.uchicago.edu/doi/full/10.1086/591066?cookieSet=1

http://www.cdc.gov/nhsn/forms/57.114_UTI_BLANK.pdf


38

Numerator: Number of Acute Care, Skilled Nursing Facility and Swing Bed inpatients with new indwelling urinary catheters inserted without appropriate indication documented

Denominator: Number of Acute Care, Skilled Nursing Facility and Swing Bed inpatients with new indwelling urinary catheter insertions

Data Sources

Self-reported


Quality staff


Providers


Frontline staff


Clinical IT

Tips and Tricks

This measure excludes straight catheters and quick catheters

Educate and ensure that Urinary Catheter insertion criteria education is provided

at new employee orientation and ongoing education throughout the year (Ex.

Monthly staff meetings and competency/skill fairs)

Criteria should include at a minimum: o Perioperative use for selected surgical procedures o Urine output monitoring in critically ill patients o Management of acute urinary retention and urinary obstruction o Assistance in pressure ulcer healing for incontinent patients o As an exception, at patient request to improve comfort (SHEA-IDSA) or for

comfort during end-of-life care (CDC)

Hospitals may add to or modify these criteria for local needs; criteria may be defined in policies or procedures

Ensure access to a bladder scanner. The bladder scanner should be kept in the same location when it is not in use to ensure prompt availability

Request that IT build the acceptable indications for inserting an indwelling catheter into your EHR. Ensure this is on your provider’s screen so they can choose an indication at time of ordering urinary catheter

Utilize a straight catheter when indicated instead of an indwelling catheter

Resources

Institute for Healthcare Improvement

http://www.ihi.org/resources/Pages/Tools/HowtoGuidePreventCatheterAssociatedUrinaryTractInfection.aspx


39

IHI How-to Guide: Prevent Catheter-Associated Urinary Tract Infections, page 24 (Login

required with free access to information)

CDC Toolkit for Reducing Catheter-Associated Urinary Tract Infections in Hospital Units

Guidelines for the use of a bladder scanner

Urinary Catheter Utilization Ratio

Numerator: Number of Acute Care, Skilled Nursing Facility and Swing Bed inpatient days with urinary catheter in place

Denominator: Number of Acute Care, Skilled Nursing Facility and Swing Bed inpatient days

Data Sources

NHSN


Quality staff


Providers


Frontline staff


Clinical IT

Tips and Tricks

Confer rights to IHC in NHSN

Provide Physician and Nurse education on Catheter Utilization

Include discussion of patients with foley catheters in place at your daily huddles and get them out if possible

Request IT put a counter in the EHR for catheter days

Pilot and spread a nurse-driven removal protocol using the electronic health record system

Every shift, document the ongoing need for the catheter based on a CDC-approved indication

Resources

Algorithm for Removal of Foley Catheter

Algorithm from Mercy Medical Center in Des Moines Iowa

CAUTI Prevention Policy

Urinary catheterization and CAUTI prevention policy document

http://www.ahrq.gov/professionals/quality-patient-safety/hais/cauti-tools/impl-guide/implementation-guide-appendix-c.html

http://www.ihconline.org/UserDocs/Pages/FoleyCatheterAlgorithmMercyDM.pdf

http://www.ihconline.org/UserDocs/Pages/CAUTI_Policy.pdf


40

Emergency Department Catheter Utilization Numerator: Number of Emergency Department urinary catheter placements in the Emergency Department Denominator: Number of Emergency Department visits

Data Sources


Self-Reported


Quality staff


Providers


Frontline staff


Clinical IT

HIM

Tips and Tricks

Educate ED staff on indications for inserting Urinary Catheters

Utilize bladder scanners

Remove unnecessary catheters before transferring to the inpatient room

Be aware of charging and coding for Urinary Catheters placed in ED

AMA CPT codes that will be utilized to identify catheters inserted in the Emergency Department: 51702, 51703

Have conversations with HIM to ask how they are coding for this measure

Resources Nurse-Initiated Removal of Unnecessary Urinary Catheters in the Non-Intensive Care Units AHRQ funded toolkit that includes appropriate use of urinary catheters and how to promote a urinary catheter removal program

Nurse Driven CAUTI Protocol Nursing urinary catheter removal protocol includes steps of care leading to catheter removal

http://www.healthynh.com/images/PDFfiles/partnership-for-patients/CAUTI-Presentations/UC%20Manual%20112010.pdf

http://www.healthynh.com/images/PDFfiles/partnership-for-patients/CAUTI-Presentations/UC%20Manual%20112010.pdf

http://www.ihconline.org/UserDocs/Pages/Nurse_Driven_CAUTI_Protocol.pdf


41

Central Line Associated Blood Stream Infections (CLABSI) A central line associated bloodstream infection (CLABSI) is a serious infection that occurs when bacteria enters the bloodstream through a central line.

These measures look at central line compliance and utilization. See below for more detailed information about each measure. The current NHSN Manual – Patient Safety Component is utilized for defining and reporting on these measures. To access the manual, follow this link: http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf. These measures help to determine how many patients are harmed by CLABSIs.

Measures Outcome Measures: Central Line-Associated Bloodstream Infection Rate

Numerator: Number of hospital-acquired, central line-associated bloodstream infections Denominator: Number of Acute Care central line catheter days

Data Sources

NHSN Recommended team members

Quality staff


Providers


Frontline staff


Lab

Tips and Tricks

Assemble an interdisciplinary team and develop an aim statement that reflects your organization's CLABSI goals

Educate and ensure that CLABSI education is provided at new employee

orientation and ongoing education throughout the year (Ex. Monthly staff meetings

and competency/skill fairs)


Include discussion of patients with central line catheters in place at your daily

huddles and get them out if possible



42

Confer your rights to IHC in NHSN

Educate patients and families about CLABSI and how it can be prevented

Resources

HRET Top Ten Checklist for CLABSI Checklist to review current interventions or initiate new interventions CDC Device-associated Module - BSI Bloodstream Infection Event (Central Line-Associated Bloodstream Infection and NON-central line-associated Bloodstream Infection) Checklist for Prevention of Central Line Associated Blood Stream Infections Checklist for providers and facilities

Institute for Healthcare Improvement How-to Guide: Prevent Central Line-Associated Bloodstream Infections, page 22. (Login required with free access to information)

FAQs About Catheter Associated Bloodstream Infections This CDC fact sheet can be used to educate patients about CLABSI. This fact sheet is also available in Spanish. To access the Spanish version of this fact sheet, click this link

CLABSI SIR (Standardized Infection Ratios) will be obtained from NHSN information

conferred to IHC and included in the analysis of statewide and national results for each

eligible facility and reported for two cohorts – one for ICUs and another for ICUs with

Other Reporting Units.

Process Measures:

Central Line Utilization Ratio Numerator: Number of central line days Denominator: Total number of patient days

Data Sources

NHSN


Quality staff


Providers


Frontline staff

http://www.hret-hen.org/topics/clabsi/HRETHEN_Checklist_CLABSI_.pdf

http://www.cdc.gov/nhsn/PDFs/pscManual/4PSC_CLABScurrent.pdf

http://www.cdc.gov/HAI/pdfs/bsi/checklist-for-CLABSI.pdf

http://www.ihi.org/resources/Pages/Tools/HowtoGuidePreventCentralLineAssociatedBloodstreamInfection.aspx

http://www.cdc.gov/hai/pdfs/bsi/BSI_tagged.pdf

http://www.cdc.gov/HAI/pdfs/bsi/SPAN_CA-BSI.pdf

http://www.cdc.gov/HAI/pdfs/bsi/SPAN_CA-BSI.pdf


43


Lab

Tips and Tricks

Include discussion of patients with central line catheters in place at your daily huddles and get them out if possible

Confer your rights to IHC in NHSN

Remove Central Lines as soon as they are not medically necessary

Resources

Joint Commission CVC Maintenance Bundles

Maintenance Bundles to reduce CLABSI Rates

Central Line Insertion Compliance

Numerator: Number of Acute Care, Skilled Nursing Facility and Swing Bed inpatients with full PICC line and/or central line catheter insertion bundle compliance Denominator: Number of Acute Care, Skilled Nursing Facility and Swing Bed inpatients with PICC line and/or central line insertions

Data Sources

Self-Reported


Quality staff


Providers


Frontline staff


Lab Tips and Tricks

Request IT build the CVC insertion and maintenance bundles into your EHR and have the nurse complete while the provider inserts the central line or maintaining the line

Adapt a central line insertion checklist to your organization and pilot its use

Avoid femoral insertion of central lines whenever possible

Bundle supplies to ensure central line supplies are readily available for use when needed

Resources

http://www.jointcommission.org/assets/1/6/CLABSI_Toolkit_Tool_3-22_CVC_Maintenance_Bundles.pdf

http://www.jointcommission.org/assets/1/6/CLABSI_Toolkit_Tool_3-22_CVC_Maintenance_Bundles.pdf


44

Joint Commission CVC Insertion Bundles

Insertion bundle components

CDC Checklist for Prevention of Central Line Associated Blood Stream Infections

Includes insertion, maintenance and hospital specific interventions

http://www.jointcommission.org/assets/1/6/CLABSI_Toolkit_Tool_3-18_CVC_Insertion_Bundles.pdf

http://www.cdc.gov/HAI/pdfs/bsi/checklist-for-CLABSI.pdf


45

Falls and Immobility Falls are the most commonly reported incidents within the healthcare setting and can increase patient risk for hospital-acquired injuries and/or immobility. If the patient is immobile, this may prolong hospitalization and decrease the patients’ ability to function. These measures look at inpatient falls resulting in fracture or dislocation, no injury, minor injury, moderate injury, major injury, death, count of assisted falls, and fall risk assessment. See below for more detailed information about each measure. These measures help to determine how many and how often patients are falling in the inpatient setting as well as how many are harmed by falls.

Measures Outcome Measures: Fall Resulting in Fracture or Dislocation (CMS HAC)

Numerator: Number of Acute Care inpatient discharges with ICD-9/10 fracture or dislocation code(s) not present on admission

Denominator: Number of Acute Care discharges

Data Sources


Self-Reported


Quality staff

Providers

Pharmacist


Frontline staff


Health Coach


HIM

Nursing Home

Home Care

Hospice



Tips and Tricks


46

Assemble an interdisciplinary team and develop an aim statement that reflects your organization's Fall Prevention goals

Educate and ensure that Fall Prevention education is provided at new employee



Participate in the HIIN Fall Prevention Community of Practice

Engage leadership on the importance of creating a just culture that allows front-line empowered to fill out incidents reports when falls occur

Include discussion of patients with fall risk at your daily huddles and individualize

their interventions for safety

Support teams in posting their “days since last fall” data

Implement Intentional rounding

Educate on and implement Post fall huddles

Show the falls videos from the Iowa Fall Prevention Task Force on your facility TV Station

Adjust your staffing according to fall risk acuity

Implement the “no pass rule” for all employees

Consider sleep cycles for inpatients. Improve light and sound levels during the night and encourage patient to be awake and active during the day if possible

Resources

HRET Top Ten Checklist for Fall Prevention Checklist to review current or initiate new interventions for fall prevention IHC HEN Falls-Dislocation Codes Complete list of ICD-10 Codes for Falls Institute for Healthcare Improvement Transforming Care at the Bedside How-to Guide: Reducing Patient Injuries from Falls (Login required with free access to information) CMS Hospital Acquired Conditions ICD-10 Codes for Falls Agency for Healthcare Research and Quality (AHRQ) Bundle of Interventions Targeting High-Risk Patients Reduces Falls and Fall-Related Injuries on Medical-Surgical Units Medscape – Managing Falls in Older People With Cognitive Impairment Patient Safety Authority

Hospital Engagement Network Falls Reduction and Prevention Collaboration Self-Assessment Tool

http://www.hret-hen.org/topics/falls/HRETHEN_Checklist_FALLS.pdf

http://www.ihconline.org/UserDocs/ICD-10_Falls-Dislocation_Codes.pdf

http://www.ihi.org/resources/Pages/Tools/TCABHowToGuideReducingPatientInjuriesfromFalls.aspx

http://www.ihi.org/knowledge/Pages/Tools/TCABHowToGuideReducingPatientInjuriesfromFalls.aspx

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/icd10_hacs.html

https://innovations.ahrq.gov/profiles/bundle-interventions-targeting-high-risk-patients-reduces-falls-and-fall-related-injuries

http://www.medscape.com/viewarticle/780055

http://patientsafetyauthority.org/EducationalTools/PatientSafetyTools/falls/Documents/self-assessment.pdf

http://patientsafetyauthority.org/EducationalTools/PatientSafetyTools/falls/Documents/self-assessment.pdf


47

Falls Prevention Process Measures Audit Tool Pennsylvania Hospital Engagement Network: Falls Reduction and Prevention Investigation Tool

Iowa Falls Prevention Coalition Videos Great for using on your facility channels. 6 videos: Falls Prevention: An Overview, In-Home Fall Hazards, Environmental/Outside Fall Hazards, Medication and Falls: How to Reduce Your Risk of Falling, Vision and Falls: How to Reduce Your Risk of Falling and Exercise and Balance for Falls Prevention

*Fall Resulting in No Apparent Injury Rate

Numerator: Number of falls for Acute Care, Skilled Nursing Facility, Swing Bed and Observation patients that have unplanned descent to the floor resulting in no visible sign of injury, stable vital signs and patient denial or pain or discomfort

Denominator: Number of patient days for Acute Care, Skilled Nursing Care, Swing Bed and Observation patient days - exclude newborn and respite patients

Data Sources

Self-Reported


Quality staff

Providers

Pharmacist


Frontline staff


Health Coach


Clinical IT

Nursing Home

Home Care

Hospice



Tips and Tricks


*Fall Resulting in Minor Injury Rate

http://patientsafetyauthority.org/EducationalTools/PatientSafetyTools/falls/Pages/audit.aspx

http://patientsafetyauthority.org/EducationalTools/PatientSafetyTools/falls/Documents/PFI.pdf

http://patientsafetyauthority.org/EducationalTools/PatientSafetyTools/falls/Documents/PFI.pdf

https://www.lifelonglinks.org/subcategory/falls-prevention-resources


48

Numerator: Number of for Acute Care, Skilled Nursing Facility, Swing Bed and Observation patients that have unplanned descent to the floor resulting in minor cuts, minor bleeding, minor skin abrasions, minor swelling and minor contusions or bruising


Data Sources

Self-Reported


Quality staff

Providers

Pharmacist


Frontline staff


Health Coach


Clinical IT

Nursing Home

Home Care

Hospice



Tips and Tricks


Severity of patient injury (as defined by the National Quality Forum): Minor: Injury that results in application of dressing, ice, cleaning of a wound, limb elevation, or topical medication

*Fall Resulting in Moderate Injury Rate

Numerator: Number of for Acute Care, Skilled Nursing Facility, Swing Bed and Observation patients that have unplanned descent to the floor resulting in excessive bleeding, lacerations requiring sutures, temporary loss of consciousness or moderate head trauma



49

Data Sources

Self-Reported


Quality staff

Providers

Pharmacist


Frontline staff


Health Coach


Clinical IT

Nursing Home

Home Care

Hospice



Tips and Tricks


Severity of patient injury (as defined by the National Quality Forum): Moderate: Injury that results in suturing, steri-strips, fracture, or splinting

*Fall Resulting in Major Injury Rate

Numerator: Number of for Acute Care, Skilled Nursing Facility, Swing Bed and Observation patients that have unplanned descent to the floor resulting in fracture, subdural hematoma, other major head trauma, cardiac arrest or patient requiring transfer to ICU or OR


Data Sources

Self-Reported


Quality staff

Providers

Pharmacist



50

Frontline staff


Health Coach


Clinical IT

Nursing Home

Home Care

Hospice



Tips and Tricks


Severity of patient injury (as defined by the National Quality Forum): Major: Injury that results in surgery, casting, or traction

*Fall Resulting in Death Rate

Numerator: Number of for Acute Care, Skilled Nursing Facility, Swing Bed and Observation patients that have unplanned descent to the floor resulting in death


Data Sources

Self-Reported


Quality staff

Providers

Pharmacist


Frontline staff


Health Coach


Clinical IT

Nursing Home

Home Care

Hospice




51

Tips and Tricks


Severity of patient injury (as defined by the National Quality Forum Death: Death as a result of a fall

*Do not include patients assisted or eased to the floor

Count of Assisted Falls

Numerator: Number of Acute Care, Skilled Nursing Facility, Swing Bed and Observation events where the patient is assisted or eased to the floor

Denominator: No denominator for this measure

Data Sources

Self-Reported


Quality staff

Providers

Pharmacist


Frontline staff


Health Coach


Clinical IT

Nursing Home

Home Care

Hospice



Tips and Tricks

Ensure that when a patient fall is included in this category that it is not counted in any other category

Process Measures:

Fall Risk Assessment on Admission

Numerator: Number of Acute Care, Skilled Nursing Facility, Swing Bed and Observation patients assessed for fall risk on admission


52

Denominator: Number of Acute Care, Skilled Nursing Facility, Swing Bed and Observation patients admitted

Data Sources

Self-Reported


Quality staff

Providers

Pharmacist


Frontline staff


Health Coach


Clinical IT

Nursing Home

Home Care

Hospice



Tips and Tricks

Educate and ensure that fall risk assessment education is provided at new

employee orientation and ongoing education throughout the year (Ex. Monthly


Include the family in discussions on patient safety and normal bathroom and sleep schedules

Initial fall risk assessment should be completed upon admission and recommended to reassess every shift or with any change of condition

Resources

AHRQ – Quality Tool Fall TIPS (Tailoring Interventions for Patient Safety) Morse Fall Scale competency manual, fall prevention behavior scale, fall prevention self-efficacy scale Morse Fall Scale Morse Fall Scale, with information on patient safety factors and patient education

Fall Risk Assessment for Older Adults: The Hendrich II Fall Risk Model Providers can use this fall risk assessment tool, intended for the acute care setting, to reduce falls by identifying individual risks for falls

https://innovations.ahrq.gov/qualitytools/fall-tips-tailoring-interventions-patient-safety

http://www.patientsafety.va.gov/docs/fallsToolkit/morse_falls_pocket_card.pdf

http://consultgerirn.org/uploads/File/trythis/try_this_8.pdf


53

CDC Steadi Toolkit Materials for providers and patients. Checklists, brochures, education, algorithm for fall assessment and interventions, video for tug test, 30 second chair stand test and 4 stage balance test

Iowa Falls Prevention Coalition Videos Great for using on your facility channels. 6 videos: Falls Prevention: An Overview, In-Home Fall Hazards, Environmental/Outside Fall Hazards, Medication and Falls: How to Reduce Your Risk of Falling, Vision and Falls: How to Reduce Your Risk of Falling and Exercise and Balance for Falls Prevention

http://www.cdc.gov/steadi/

https://www.lifelonglinks.org/subcategory/falls-prevention-resources


54

Pressure Ulcers Pressure ulcers occur frequently within the hospital setting. Pressure ulcers are staged on severity and are localized to the skin and tissue. These measures look at the number of inpatients (Acute Care, Skilled Nursing, Swing Bed) receiving full preventive care and the number who have a pressure ulcer diagnosis code. See below for more detailed information about each measure. These measures help to determine how many patients are harmed by pressure ulcers.

Measures

Outcome Measure: Pressure Ulcer Rate, Stage 3+ (AHRQ)

Numerator: Number of Acute Care, Skilled Nursing Facility and Swing Bed inpatients with ICD-9/10 code(s) for pressure ulcer AND secondary ICD-9/10 diagnosis code(s) for Stage III, Stage IV or unstageable pressure ulcer, non-POA

Denominator: Number of at-risk Acute Care, Skilled Nursing Facility and Swing Bed inpatients

Data Sources


Self-Reported


Quality staff

Providers


Frontline staff


Health Coach


Clinical IT

HIM

Nursing Home

Home Care

Hospice

Wound/ostomy staff



Dietitian


55

Tips and Tricks

Refer to AHRQ PSI 3 technical specifications for exclusions

Assemble an interdisciplinary team and develop an aim statement that reflects your organization's Pressure Ulcer goals

Educate and ensure that Pressure Ulcer education is provided at new employee



Include discussion of patients with pressure ulcers at your daily huddles and

ensure they are receiving the full pressure ulcer preventative care

Ensure that your providers and nurses are consistent with documentation of pressure ulcers

Resources

HRET Top Ten Checklist for Pressure Ulcer Checklist to review current or initiate new interventions for HAPU prevention National Pressure Ulcer Advisory Panel NPUAP Pressure Ulcer Stages/categories ARHQ – Preventing Pressure Ulcers in Hospitals Skin assessment, pressure ulcer risk assessment and planning and implementation ideas

National Pressure Ulcer Advisory Panel - Quick Reference Guide Prevention, Interventions and Treatment of Pressure Ulcers Agency for Healthcare Research and Quality (AHRQ) Pressure Ulcer Rate Patient Safety Indicators #3

Process Measure: At-Risk Patients Receiving Full Pressure Ulcer Preventative Care

Numerator: Number of at-risk Acute Care, Skilled Nursing Facility and Swing Bed inpatients receiving full pressure ulcer preventative care

Denominator: Number of at-risk Acute Care, Skilled Nursing Facility and Swing Bed inpatients

Data Sources

Self-Reported


Quality staff

http://www.hret-hen.org/topics/pu/HRETHENPRU_Checklist_ChangePackage.pdf

http://www.npuap.org/wp-content/uploads/2012/01/NPUAP-Pressure-Ulcer-Stages-Categories.pdf

http://www.ahrq.gov/professionals/systems/hospital/pressureulcertoolkit/putool3.html

http://www.npuap.org/wp-content/uploads/2014/08/Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-Jan2016.pdf

http://qualityindicators.ahrq.gov/Downloads/Modules/PSI/V50-ICD10/TechSpecs/PSI%2003%20Pressure%20Ulcer%20Rate.pdf


56

Providers


Frontline staff


Health Coach


Clinical IT

Wound/ostomy staff


Dietitian

Tips and Tricks

Educate and ensure that Braden scale and pressure ulcer preventative care

education is provided at new employee orientation and ongoing education

throughout the year (Ex. Monthly staff meetings and competency/skill fairs)

Proper pressure ulcer care includes the following six components: o Conduct a pressure ulcer admission assessment for all patients o Reassess risk daily for every patient o Inspect skin daily o Manage moisture: keep the patient dry and moisturize the skin o Optimize nutrition and hydration o Minimize pressure (Turn/Reposition every two hours and use pressure-

redistribution surfaces)

This measure follows an “all-or-none” format. All components must be performed (or contraindications documented) for compliance to be recorded

Request that IT build the pressure ulcer care components into your EHR

Resources

Braden Scale Instructions and scoring Institute for Healthcare Improvement How-to Guide: Prevent Pressure Ulcers (Login required with free access to information)

http://www.healthcare.uiowa.edu/igec/tools/pressureulcers/bradenscale.pdf

http://www.ihi.org/resources/Pages/Tools/HowtoGuidePreventPressureUlcers.aspx


57

Readmissions and Care Coordination Readmissions are defined as several admissions, inpatient stays, to a hospital or

multiple hospitals by one patient within 30 days.

These measures look at the internal processes (e.g. patient teach-back and

communications) used to reduce hospital readmissions, as well as outcome measures,

looking at the number of acute care inpatient discharges meeting the all-cause 30-day

readmission criteria.

These measures help to determine how many and how often patients are readmitted.

Measures Outcome Measures: Unplanned All-Cause, 30-Day Readmissions to Any Hospital

Numerator: Number of Acute Care inpatient discharges that meet criteria inclusion as a readmission to any hospital using unplanned, 30- day, all-cause, all-payer methodology

Denominator: Number of Acute Care Inpatient discharges meeting eligibility for inclusion as an index admission Data Sources


Self-Reported


Quality staff

Providers

Pharmacist


Frontline staff


Health Coach


HIM

Nursing Home

Home Care

Tips and Tricks

Claims based data or IPOP data: To get data that is real time make sure your readmission claims are being submitted monthly, talk with you IPOP submitter about monthly vs. quarterly submissions


58

Assemble an interdisciplinary team and develop an aim statement that reflects your organization's Care Transition goals

Partner with family caregivers in the hospital, to help ensure safe transitions

Develop and lead a Community Care Coalition

Ensure that prescriptions are filled prior to discharge

Include Pharmacist in medication reconciliation and education upon admission and discharge

Encourage patient participation in developing a discharge planning tool to reinforce the discharge plan

Implement system for follow up phone calls to discharged patients within 24-72 hours of discharge

Remove exclusions from your numerator population (planned readmissions like chemotherapy, radiation, rehab, planned surgery, renal dialysis). The number of (index) discharges that resulted in readmissions within 30 days will be your numerator

Remove exclusions from the denominator population (transfers to other acute care, deceased before discharge, Labor and Delivery). The number of discharges after you remove the exclusions is your denominator (or “index discharges”)

Resources HRET Top Ten Checklist for Readmissions A checklist to review current, or initiate new interventions to prevent avoidable readmissions in your facility

IHI Effective Interventions to Reduce Rehospitalizations Includes: RED: Re-Engineered Discharge, Transitional Care Model, Care Transitions Program and many more ways to help with discharges

AHA HRET Hospital Engagement Network – Resources Resources to drive improvement in Preventable Readmissions – Suggested resources: Hospital Guide to Reducing Medicaid Readmissions AHRQ; Risk Assessment tools, Preventable Readmission. Change Package; Preventable Readmission Checklist, click on topics and choose readmissions

Center for Healthcare Research and Transformation – Care Transitions: Best Practices and Evidence-based Programs Best practices in Care Transitions

Institute for Healthcare Improvement Overview State Action on Avoidable Re-hospitalizations – STAAR Model Unplanned All-Cause, 30-Day Readmission to the Same Hospital

http://www.hret-hen.org/topics/readmissions/HRETHEN_Checklist_Readmissions.pdf

http://www.ihi.org/resources/Pages/Changes/EffectiveInterventionstoReduceRehospitalizationsCompendium15PromisingInterventions.aspx


http://www.hret-hen.org/index.php?option=com_phocadownload&view=category&id=179&Itemid=280

http://www.ihi.org/Engage/Initiatives/Completed/STAAR/Pages/default.aspx


59

Numerator: Number of Acute Care inpatient discharges that meet criteria inclusion as a readmission to the same hospital using unplanned, 30-day, all-cause, all-payer methodology

Denominator: Number of Acute Care inpatient discharges meeting eligibility for inclusion as an index admission Data Sources

IPOP/Claims data (where available) Self-reported


Quality staff

Providers

Pharmacist


Frontline staff


Health Coach


HIM

Nursing Home

Home Care

Tips and Tricks

Claims based data or IPOP data: To get data that is real time make sure your readmission claims are being submitted monthly, talk with you IPOP submitter about monthly vs. quarterly submissions

Assemble an interdisciplinary team and develop an aim statement that reflects your organization's Care Transition goals

Partner with family caregivers in the hospital, to help ensure safe transitions

Develop and lead a Community Care Coalition

Fill prescriptions prior to discharge

Include Pharmacist in medication reconciliation and education upon admission and discharge

Encourage patient participation in developing a discharge planning tool to reinforce the discharge plan

Implement system for follow up phone calls to discharged patients within 24-72 hours of discharge

Remove exclusions from your numerator population (planned readmissions like chemotherapy, radiation, rehab, planned surgery, renal dialysis). The number of (index) discharges that resulted in readmissions within 30 days will be your numerator


60

Remove exclusions from the denominator population (transfers to other acute care, deceased before discharge, Labor and Delivery). The number of discharges after you remove the exclusions is your denominator (or “index discharges”)

Resources HRET Top Ten Checklist for Readmissions A checklist to review current, or initiate new interventions to prevent avoidable readmissions in your facility

AHA HRET Hospital Engagement Network – Resources Resources to drive improvement in Preventable Readmissions – Suggested resources: Hospital Guide to Reducing Medicaid Readmissions AHRQ; Risk Assessment tools, Preventable Readmission. Change Package; Preventable Readmission Checklist, click on topics and choose readmissions

IHI Effective Interventions to Reduce Rehospitalizations Includes: RED: Re-Engineered Discharge, Transitional Care Model, Care Transitions Program and many more ways to help with discharges

Center for Healthcare Research and Transformation – Care Transitions: Best Practices and Evidence-based Programs Best practices in Care Transitions

Institute for Healthcare Improvement Overview State Action on Avoidable Re-hospitalizations – STAAR Model

Process Measures: Patient Teach-Back

Numerator: Number of observations of nurses where teach-back is used to assess understanding

Denominator: Number of observations of nurse teaching

Data Sources

Self-Reported


Quality staff

Providers

Pharmacist


Frontline staff

http://www.hret-hen.org/topics/readmissions/HRETHEN_Checklist_Readmissions.pdf

http://www.hret-hen.org/index.php?option=com_phocadownload&view=category&id=179&Itemid=280



http://www.ihi.org/Engage/Initiatives/Completed/STAAR/Pages/default.aspx


61


Health Coach


Tips and Tricks

Educate and ensure that Teach-back education is provided at new employee



Utilize the suggested teach-back questions to patients to make sure they understand discharge instructions

Assessment can be provided via direct observation or someone other than the discharge nurse can go in and assess the patient and family understanding for teach-back

Resources Can Teach-back Reduce Hospital Readmissions Teach-back essentials

AHRQ Health Literacy Universal Precautions Toolkit, 2nd Edition Teach-back and health literacy information, includes a Teach-Back Observation Tool!

Always Use Teach-back Toolkit that includes interactive teach-back learning modules, coaching to always use teach-back, resources and videos

Community Provider Involvement in Identifying Post-Discharge Needs Numerator: Number of Acute Care, Skilled Nursing Facility and Swing Bed inpatient discharges where community providers (e.g. home care, primary care, nurses, skilled nursing) were included in assessing post discharge needs

Denominator: Number of discharges for Acute Care, Skilled Nursing Care and Swing Bed inpatient discharges

Data Sources

Self-Reported


Quality staff

Providers

Pharmacist


Frontline staff


http://www.americannursetoday.com/assets/0/434/436/440/11262/11264/11276/11324/9749f142-1233-46c5-9969-3282d8b0c144.pdf

http://www.americannursetoday.com/assets/0/434/436/440/11262/11264/11276/11324/9749f142-1233-46c5-9969-3282d8b0c144.pdf

http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/healthlittoolkit2-tool5.html

http://www.teachbacktraining.org/assets/files/PDFS/Teach%20Back%20-%20Observation%20Tool.pdf

http://www.teachbacktraining.org/


62

Health Coach


Physical/Occupational/Speech Therapy

Dietitian

Nursing Home

Home Care

Hospice

Tips and Tricks

Ensure that the patient to be discharged is assessed for ongoing needs after discharge

This measure is met by including at least one of the providers in parentheses, you do not need all resources listed

Include documentation of communication of a discharge plan discussed with one of the community providers listed or have the community provider document their participation

Resources Becker’s Infection Control and Clinical Quality, Why Improving Communication May Be the Key to Reducing Readmissions Preventing readmissions by including post-acute care providers in the discharge plan

Post-Hospital Follow-Up Appointment

Numerator: Number of Acute Care, Skilled Nursing Facility and Swing Bed inpatient discharges with follow-up appointment scheduled before discharge in accordance with risk assessment Denominator: Number of discharges for Acute Care, Skilled Nursing Care and Swing Bed inpatient discharges

Data Sources

Self-reported Recommended team members

Quality staff

Providers

Pharmacist


Frontline staff


Health Coach


http://www.beckershospitalreview.com/quality/why-improving-communication-may-be-the-key-to-reducing-readmissions.html

http://www.beckershospitalreview.com/quality/why-improving-communication-may-be-the-key-to-reducing-readmissions.html


63

Tips and Tricks

Develop and implement a system for evenings, weekends and holidays and follow up on the next business day, this will meet the measure

Develop a system to ensure the communication loop has been closed and the patient has an appointment from the clinic

Ensure the discharge appointment process is someone’s responsibility, delegating this responsibility with ensure consistency of the process

Use the LACE readmissions risk assessment tool to determine readmission risk classification and associated timeline for follow-up appointment

Recommended follow-up time frames: o High risk 3-5days o Moderate risk 5-7 days o Low or no risk 7-14 days

Ensure physician documentation is provided if no follow-up is necessary Resources Lace Tool

Society of Hospital Medicine – Follow-up Appointments Project BOOST Implementation Toolkit Tools and implementation tips for follow-up appointments

Handover Communication

Numerator: Number of Acute Care, Skilled Nursing Facility and Swing Bed inpatient discharges where critical information is transmitted to the next site of care (e.g. office, PCP, LTC, HH) or person continuing care

Denominator: Number of discharges for Acute Care, Skilled Nursing Care and Swing Bed inpatient discharges

Data Sources

Self-Reported Recommended team members

Quality staff

Providers


Frontline staff


Health Coach


Doctor Office/Clinic Staff

Nursing Home

http://micmrc.org/system/files/LACE_tool%20word%204.23.13.pdf

http://www.hospitalmedicine.org/Web/Quality_Innovation/Implementation_Toolkits/Project_BOOST/Web/Quality___Innovation/Implementation_Toolkit/Boost/BOOST_Intervention/Tools/Follow_Up_Appointments.aspx

http://www.hospitalmedicine.org/Web/Quality_Innovation/Implementation_Toolkits/Project_BOOST/Web/Quality___Innovation/Implementation_Toolkit/Boost/BOOST_Intervention/Tools/Follow_Up_Appointments.aspx


64

Home Care

Hospice Tips and Tricks

Educate staff on hospitals standardized approach to handover communication

Critical information includes: ***Vital signs, medication list, allergies, daily habits (bathroom, ambulatory, dietary, sleep), fall risk, available lab and test results

Ensure system for sending pending lab and test results once they are available if not available at the time of transfer

Resources AHRQ Handoffs and Signouts Includes inpatient and discharge handovers. I-PASS study

https://psnet.ahrq.gov/primers/primer/9/handoffs-and-signouts


65

Severe Sepsis and Septic Shock Sepsis is an inflammatory response to infection and can be life-threatening. Sepsis is also referred to as “blood poisoning.” Measures focus on diagnosis of Sepsis (Postoperative sepsis and sepsis rate) and severe sepsis and septic shock management bundle compliance. The current NHSN Manual – Patient Safety Component is utilized for defining and reporting on these measures. To access the manual, follow this link: http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf. See below for more detailed information about each measure. These measures will help to determine how many and how often patients are harmed by Sepsis.

Measures

Outcome Measure: Postoperative Sepsis Rate, (AHRQ PSI 13)

Numerator: Number of Acute Care elective surgical inpatient discharges with any secondary ICD-9/10 diagnosis code for sepsis

Denominator: Number of Acute Care elective surgical inpatient discharges with any-listed ICD-9/10 procedure code for an operating room procedure and admission type recorded as elective

Data Sources


Self-Reported


Quality staff


Providers

Pharmacist


Frontline staff


Health Coach


HIM

Nursing Home

Home Care

Hospice



66

Wound/ostomy staff

Lab


Dietitian

Tips and Tricks

Assemble an interdisciplinary team and develop an aim statement that reflects your organization's Sepsis goals

Educate and ensure that Sepsis education is provided at new employee




Resources HRET Top Ten Checklist for Sepsis Checklist to review current or initiate new sepsis mortality reduction interventions NQF-Endorsed Voluntary Consensus Standard for Hospital Care Measure information collected for: CMS Voluntary Only – Surgical Care Improvement Project (SCIP) AHRQ Selected Best Practices and Suggestions for Improvement PSI 13: Postoperative Sepsis Recommended practices, best processes, and educational recommendations

Process Measures: Severe Sepsis and Septic Shock 3-hour Management Bundle Compliance (NQF 0500)

Numerator: Number of Acute Care, Skilled Nursing Facility and Swing Bed inpatients in the denominator population who receive all elements of the 3 hour Severe Sepsis and Septic Shock Management Bundle

Denominator: Number of Acute Care, Skilled Nursing Facility and Swing Bed inpatients presenting with severe sepsis or septic shock (exclude patients comfort care only, where central line cannot be placed or is contraindicated, or where clinical condition precludes total measure completion)

Data Sources

Self-Reported


Quality staff


http://www.hret-hen.org/topics/sepsis/HRETHEN_Checklist_Sepsis.pdf

http://www.ihconline.org/UserDocs/2z_SCIP-Inf-10.pdf

http://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/d4m-sepsis-bestpractices_.pdf

http://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/d4m-sepsis-bestpractices_.pdf


67

Providers

Pharmacist


Frontline staff


Clinical IT

Lab


Tips and Tricks


Educate and ensure that Sepsis bundle education is provided at new employee



Include discussion of patients at risk or diagnosed with Sepsis at your daily

huddles

Severe Sepsis Screening

o Is the patient’s history suggestive of a new infection?

o Are 2 of the following new to the patient and present?

Hyperthermia > 38.3 Celsius

Hypothermia < 36 Celsius

Altered mental status

Tachycardia > 90 bpm

Tachypnea > 20 bpm

Leukocytosis (WBC > 12000)

Leukopenia (WBC count< 4000)

Hyperglycemia (Plasma glucose > 140 mg/dl) or 7.7 mmol/L in the absence

of diabetes

If answer is yes to the above 2 questions, suspicion of infection is present

o Organ dysfunction criteria

SBP < 90 mmHg or MAP <65 mmHg

SBP decrease > 40 mmHg from baseline

Creatinine > 2.0 mg/dl or urine output < 0.5 ml/kg/hour for 2 hours

Bilirubin > 2 mg/dl

Platelet count < 100,000

Lactate > 2 mmol/L

INR >1.5 or PTT > 60 secs

Acute lung injury with a PaO2/Fio2 <250 in the absence of pneumonia as an

infection source

Acute lung injury with a PaO2/Fio2 <200 in the presence of pneumonia as an

infection source


68

If suspicion of infection and organ dysfunction is present, the patient meets

criteria for Severe Sepsis

This measure is for inpatients and excludes ER. We encourage you to implement all bundles into ER as well as inpatients

Request that IT build a Sepsis alert into your triage, admission and nursing assessments

Develop a tracking sheet for every person screened with sepsis at triage and/or admission to stay on their chart until discharge or have the order sets built into EHR

Ensure the 2nd lactate is ordered the same time as the first lactate

Educate Patients and Families on how to recognize sepsis in yourself and family members

Utilize the Surviving Sepsis Campaign Implementation Guide

Resources

Sepsis Bundle Project (SEP) – National Hospital Inpatient Quality Measures SEP Measure Set Table, last updated version 5.0a. Sepsis initial patient population algorithm

Surviving Sepsis Campaign Updated Bundles in Response to New Evidence Surviving Sepsis Campaign – Tool Evaluation for Severe Sepsis Screening Tool

Evaluation for Severe Sepsis Screening Tool This is an optional tool to assist in screening patients for severe sepsis within three patient care settings: the emergency department, medical/surgical floors, or in the ICU

Severe Sepsis and Septic Shock 6-hour Management Bundle Compliance (NQF 0500)

Numerator: Number of Acute Care, Skilled Nursing Facility and Swing Bed inpatients in the denominator population who receive all elements of the 6-hour Severe Sepsis and Septic Shock Management Bundle

Denominator: Number of Acute Care, Skilled Nursing Facility and Swing Bed inpatients presenting with severe sepsis or septic shock (exclude patients comfort care only, where central line cannot be placed or is contraindicated, or where clinical condition precludes total measure completion)

Data Sources

Self-Reported

http://www.ihconline.org/UserDocs/Sepsis_Bundle_Project_SEP_Measure_Set.pdf

http://www.survivingsepsis.org/SiteCollectionDocuments/SSC_Bundle.pdf

http://www.survivingsepsis.org/SiteCollectionDocuments/ScreeningTool.pdf



69


Quality staff


Providers

Pharmacist


Frontline staff


Clinical IT

Lab


Tips and Tricks


Educate and ensure that Sepsis bundle education is provided at new employee orientation and ongoing education throughout the year (Ex. Monthly staff meetings and competency/skill fairs)

Include discussion of patients at risk or diagnosed with Sepsis at your daily huddles

This measure is for inpatients and excludes ER. We encourage you to implement all bundles into ER as well as inpatients

Request that IT build a Sepsis alert into your triage, admission and nursing assessments

Develop a tracking sheet for every person screened with sepsis at triage and/or admission to stay on their chart until discharge or have the order sets built into EHR

Ensure the 2nd lactate is ordered the same time as the first lactate

Educate Patients and Families on how to recognize sepsis in yourself and family members

Utilize the Surviving Sepsis Campaign Implementation Guide

Resources

Sepsis Bundle Project (SEP) – National Hospital Inpatient Quality Measures SEP Measure Set Table, last updated version 5.0a. Sepsis initial patient population algorithm

Surviving Sepsis Campaign Updated Bundles in Response to New Evidence Surviving Sepsis Campaign – Tool Evaluation for Severe Sepsis Screening Tool

http://www.ihconline.org/UserDocs/Sepsis_Bundle_Project_SEP_Measure_Set.pdf

http://www.survivingsepsis.org/SiteCollectionDocuments/SSC_Bundle.pdf



70

Surgical Site Infection (SSI) A surgical site infection (SSI) occurs after a surgery, in the part of the body where the surgery took place. Surgical site infections can sometimes be superficial infections only involving the skin. Other SSIs are more serious and can involve tissues under the skin, organs, or implanted material. The process measures look at surgical safety checklist compliance and temperature management. The Outcome measures focus on infection rates per number of surgical episodes. See below for more detailed information about each measure. The current NHSN Manual – Patient Safety Component is utilized for defining and reporting on these measures. To access the manual, follow this link: http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf. These measures help to determine how many patients are harmed by SSIs.

Measures Outcome Measures: Colon Surgical Site Infection Rate

Numerator: Number of hospital-acquired colon surgical site infections

Denominator: Number of colon surgical episodes

Data Sources

NHSN


Quality staff


Providers


Frontline staff


Lab

HIM


Tips and Tricks

Report when your facility performs 10 or more Colon surgeries in a year

Assemble an interdisciplinary team and develop an aim statement that reflects your organization's SSI goals



71

Educate and ensure that SSI education is provided at new employee orientation




Develop a system to provide consistent SSI reporting from Surgeons

Provide patient and family education on SSI and how they can be prevented

Avoid using flash sterilization for convenience, as an alternative to purchasing additional instrument sets, or to save time

Ensure clinical practice aligns with the most recent guidelines for antimicrobial prophylaxis in surgery

Utilize TeamSTEPPS tools such as "check back" when communicating with other health care professionals

Resources

HRET Top Ten Checklist for SSI

CDC Surgical Site Infection Event

ICD-10 PCS and CPT Mapping, wound classes, SSI criteria and SSI event reporting

instructions

AHRQ Postoperative Sepsis Rate PSI #13

ICD-9 and ICD-10 codes and descriptions

CDC Surgical Site Infection SSI Event

Surgical Site Infection (SSI) Toolkit

CDC Toolkit is organized as a PowerPoint document and includes SSI prevention

strategies

Frequently Asked Questions About Surgical Site Infections

The CDC provides answers to the most frequently asked questions about SSIs

Abdominal Hysterectomy Surgical Site Infection Rate

Numerator: Number of hospital-acquired abdominal hysterectomy surgical site infections

Denominator: Number of abdominal hysterectomy surgical episodes

Data Sources

NHSN

http://www.hret-hen.org/topics/ssi/HRETHEN_Checklist_SSI.pdf

http://www.cdc.gov/nhsn/PDFs/pscManual/9pscSSIcurrent.pdf

http://qualityindicators.ahrq.gov/Downloads/Modules/PSI/V50-ICD10/TechSpecs/PSI%2013%20Postoperative%20Sepsis%20Rate.pdf

http://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf

http://www.cdc.gov/HAI/pdfs/toolkits/SSI_toolkit021710SIBT_revised.pdf

http://www.cdc.gov/HAI/ssi/faq_ssi.html


72


Quality staff


Providers


Frontline staff


Lab

HIM


Tips and Tricks

Report when your facility performs 10 or more Abdominal Hysterectomy surgeries in a year










Resources HRET Top Ten Checklist for SSI



instructions



Hip Replacement Surgical Site Infection Rate

Numerator: Number of hospital-acquired hip replacement surgical site infections

Denominator: Number of hip replacement surgical episodes





73

Data Sources

NHSN


Quality staff


Providers


Frontline staff


Lab

HIM


Tips and Tricks

Report when your facility performs 10 or more Hip Replacement surgeries in a year










Resources

HRET Top Ten Checklist for SSI



instructions



IHI How to Guide: Prevent Surgical Site Infection for Hip and Knee Arthroplasty




http://www.ihi.org/resources/pages/tools/howtoguidepreventssiforhipkneearthroplasty.aspx


74

Evidence supporting interventions and how to implement to prevent SSI for hip and

knee arthroplasty

Guide to the Elimination of Orthopedic Surgical Site Infections

This guide created and presented by APIC will help healthcare providers reduce

orthopedic SSIs

Knee Replacement Surgical Site Infection Rate Numerator: Number of hospital-acquired knee replacement surgical site infections

Denominator: Number of knee replacement surgical episodes

Data Sources

NHSN


Quality staff


Providers


Frontline staff


Lab

HIM


Tips and Tricks

Report when your facility performs 10 or more Knee Replacement surgeries in a year









http://www.apic.org/Resource_/EliminationGuideForm/34e03612-d1e6-4214-a76b-e532c6fc3898/File/APIC-Ortho-Guide.pdf


75


Resources HRET Top Ten Checklist for SSI CDC Surgical Site Infection Event


instructions


ICD-9 and ICD-10 codes and descriptions IHI How to Guide: Prevent Surgical Site Infection for Hip and Knee Arthroplasty

Evidence supporting interventions and how to implement to prevent SSI for hip and

knee arthroplasty

Guide to the Elimination of Orthopedic Surgical Site Infections

This guide created and presented by APIC will help healthcare providers reduce

orthopedic SSIs

Process Measures: Surgery Patients with Perioperative Temperature Management

Numerator: Number of surgical inpatients for whom either active warming was used intraoperatively or who had at least one body temperature equal to or greater than 96.8F/36C within 30 minutes immediately prior to or 15 minutes immediately after anesthesia end time Denominator: Number of surgical inpatients undergoing procedure under general or neuraxial anesthesia of greater than or equal to 60 minutes duration

Data Sources

Self-Reported


Quality staff


Providers


Frontline staff


Clinical IT




http://www.ihi.org/resources/pages/tools/howtoguidepreventssiforhipkneearthroplasty.aspx

http://www.apic.org/Resource_/EliminationGuideForm/34e03612-d1e6-4214-a76b-e532c6fc3898/File/APIC-Ortho-Guide.pdf


76

Tips and Tricks

Educate the patient and family prior to the day of surgery of the importance normothermia begins in the home and during the travel to the hospital

Educate hospital staff to keep the patient warm prior to an immediately after surgery and document temperature and interventions accordingly

Resources

HOAJ Perioperative temperature measurement and management

SCIP measurement and maintenance of normothermia. Indications for intraoperative

hypothermia

American Society of Anesthesiologists Perioperative Temperature Management

Preoperative and Intraoperative recommendations and interventions

Surgical Safety Checklist Compliance Numerator: Number of operating room procedures in which the checklist was used

Denominator: Number of operating room procedures during the observed time period

Data Sources


Quality staff


Providers


Frontline staff


Clinical IT

Tips and Tricks

This does not include colonoscopy, endoscopy

Provide staff education of the importance of the surgical safety checklist

Request that IT build the surgical safety checklist into the EHR

Audit annually to ensure the surgical safety checklist is being utilized correctly

Resources

World Health Organization Patient Safety

http://www.hoajonline.com/jacs/2049-9752/2/8

http://www.hoajonline.com/jacs/2049-9752/2/8

http://www.who.int/patientsafety/safesurgery/ss_checklist/en/


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Surgical safety checklist and implementation manual


78

Ventilator Associated Events (VAE) Ventilator-associated events (VAEs) are events associated to the use of mechanical ventilation in the inpatient setting. These measures look at ventilator bundle compliance and the number of events that meet VAC, IVAC, and possible/probable criteria. See below for more detailed information about each measure. The current NHSN Manual – Patient Safety Component is utilized for defining and reporting on these measures. To access the manual, follow this link: http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf.

These measures help to determine how many and how often patients are harmed by VAEs.

Measures Outcome Measures: Ventilator-Associated Condition (VAC)

Numerator: Number of events that meet VAC criteria

Denominator: Number of ventilator days

Data Sources

NHSN


Quality staff


Providers


Frontline staff




Tips and Tricks

Assemble an interdisciplinary team and develop an aim statement that reflects your organization's VAE goals

Educate and ensure that VAE education is provided at new employee orientation






79

Include discussion of patients on mechanical ventilators at your daily huddles

and the progress toward extubation


Avoid intubation and use noninvasive positive pressure ventilation when feasible

Develop a clear understanding of the VAE surveillance definitions and work to partially or completely automate VAE detection

Ensure that the head of the bed is elevated 30 to 45 degrees while visiting your family member who is on ventilator

Implement the ABCDE bundle to prevent delirium, prolonged ventilation and physical deterioration

Resources HRET Top Ten Checklist for VAE Top 10 evidence based interventions CDC Device-associated Module Ventilator-Associated Event (VAE) National Healthcare Safety Network Surveillance for Ventilator-Associated Events - resources for NHSN users already enrolled

Infection-Related Ventilator-Associated Complication (IVAC) Numerator: Number of events that meet IVAC criteria


Data Sources

NHSN


Quality staff


Providers


Frontline staff



Lab

Tips and Tricks


http://www.hret-hen.org/topics/vae/13-14/2014-VAEChecklist.pdf

http://www.cdc.gov/nhsn/pdfs/pscmanual/10-vae_final.pdf

http://www.cdc.gov/nhsn/acute-care-hospital/vae/


80

Include adult locations only





Resources

HRET Top Ten Checklist for VAE Top 10 evidence based interventions CDC Device-associated Module Ventilator-Associated Event (VAE) National Healthcare Safety Network Surveillance for Ventilator-Associated Events - resources for NHSN users already enrolled

Possible/Probable Ventilator-Associated Pneumonia

Numerator: Number of events that meet possible/probable Ventilator- Associated Pneumonia criteria


Data Sources

NHSN


Quality staff


Providers


Frontline staff




Lab

Tips and Tricks


http://www.hret-hen.org/topics/vae/13-14/2014-VAEChecklist.pdf

http://www.cdc.gov/nhsn/pdfs/pscmanual/10-vae_final.pdf

http://www.cdc.gov/nhsn/acute-care-hospital/vae/


81

Include adult locations only





Resources

Institute for Healthcare Improvement How-to Guide: Prevent Ventilator-Associated Pneumonia, page 27. (Login required with

free access to information)

VAP: Patient and Family Education Sheet

Providers can use this one-page document to help inform patients about the risk of VAP

and prevention strategies utilized in hospitals

Process Measure: Ventilator Bundle Compliance

Numerator: Number of ICU patients in the denominator population on mechanical ventilation with full ventilator-associated prevention bundle compliance

Denominator: Number of ICU patients on mechanical ventilation on day of week of sample

Data Sources

Self-Reported


Quality staff


Providers

Pharmacist


Frontline staff




Tips and Tricks

http://www.ihi.org/resources/Pages/Tools/HowtoGuidePreventVAP.aspx

https://northwest-hospitals.kaiserpermanente.org/sites/default/files/content_files/documents/PreventingInfections_VentilatorAssociated.pdf


82

Educate and ensure that Ventilator Bundle Compliance education is provided at

new employee orientation and ongoing education throughout the year (Ex. Monthly


Educate staff on the five components of care: o Elevation of the Head (30-45 degrees) o Daily Sedative Interruption and Daily Assessment of Readiness to

Extubate o Peptic Ulcer Disease Prophylaxis o Deep Venous Thrombosis Prophylaxis o Daily Oral Care with Chlorhexidine

This measure follows an “all-or-none” format. All components must be performed (or contraindications documented) for compliance to be recorded

Request that IT builds the five components of care into the EHR

Resources

Institute for Healthcare Improvement

How-to Guide: Prevent Ventilator-Associated Pneumonia, page 10-20. (Login required

with free access to information)

http://www.ihi.org/resources/Pages/Tools/HowtoGuidePreventVAP.aspx


83

Venous Thromboembolism (VTE) Venous Thromboembolism (VTE) refers to conditions in which unwanted blood clots form in the body. These clots include both Deep Vein Thrombosis (DVT) and Pulmonary Embolisms (PE). These measures focus on the number post-operative PE or DVT and utilization of appropriate VTE prophylaxis. See below for more detailed information about each measure. These measures help to determine how many and how often patients are harmed by

VTE.

Measures

Outcome Measure:

Post-Operative Pulmonary Embolism (PE) or Deep Venous Thrombosis (DVT) (AHRQ)

Numerator: Number of Acute Care surgical inpatients with non-POA secondary ICD-9/10 code(s) for DVT or PE

Denominator: Number of Acute Care surgical inpatient discharges excluding cases where DVT/PE are present on admission

Data Sources


Self-Reported


Quality staff

Providers

Pharmacist


Frontline staff


Health Coach


HIM

Nursing Home

Home Care

Wound/ostomy staff


Lab


84


Dietitian

Tips and Tricks

Assemble an interdisciplinary team and develop an aim statement that reflects your organization's VTE goals

Educate and ensure that VTE education is provided at new employee orientation



Ensure that your Pharmacist is involved

Request that IT builds in a hard stop on risk factors for VTE

Resources

HRET Top Ten Checklist for VTE Top ten evidence based interventions Agency for Healthcare Research and Quality (AHRQ) Perioperative Pulmonary Embolism or Deep Vein Thrombosis Rate, PSI #12

Process Measure:

VTE Appropriate Prophylaxis

Numerator: Number of Acute Care, Skilled Nursing Facility, Swing Bed and Observation patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given

Denominator: Number of admissions to Acute Care, Skilled Nursing Facility, Swing Bed and Observation patients with stays of >48 hours

Data Sources

Self-Reported


Quality staff

Providers

Pharmacist


Frontline staff


Clinical IT

Lab

Dietitian

http://www.hret-hen.org/topics/vte/13-14/2014-VTEChecklist.pdf

http://qualityindicators.ahrq.gov/Downloads/Modules/PSI/V50-ICD10/TechSpecs/PSI%2012%20Perioperative%20Pulmonary%20Embolism%20or%20Deep%20Vein%20Thrombosis%20Rate.pdf


85

Tips and Tricks

If possible, build a hard stop into your EHR for an in

Cover this in daily huddle

Follow your policy on VTE prophylaxis according to your medical director

Distribute provider-level dashboards, allowing providers to see their VTE prophylaxis ordering rates and compare them to other benchmarks

Patient education on Recognizing VTE symptoms and understand VTE treatment options

Design and implement an appropriate VTE protocol with standardized order sets

Pharmacist's role in VTE prevention

Pharmacist-led program to improve venous thromboembolism prophylaxis in a community hospital

Risk Factors for VTE:

o Age over 60 years

o Critical care admission

o Dehydration

o Known thrombophilia

o Obesity

o One or more significant medical comorbidities (heart disease, metabolic, endocrine or

o respiratory pathologies; acute infectious diseases; inflammatory conditions)

o History of VTE

o Use of hormone replacement therapy

o Use of estrogen-containing contraceptive therapy

o Varicose veins with associated phlebitis

o Fracture of pelvis/hip/lower extremity

o Active cancer or cancer treatment

o Indwelling central venous catheter

o Immobility

Resources AHRQ Preventing Hospital-Acquired Venous Thromboembolism Framework for improvement, evidence and best practices, VTE prevention protocol and interventions

AHRQ Quality Indicators Toolkit Selected Best Practices and Suggestions for Improvement, PE and DVT

National Blood Clot Alliance Community members can use this link to access resources from the National Blood Clot Alliance, an organization that is dedicated to DVT/PE prevention. Resources available

http://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/vtguide/vteguide.pdf

http://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/vtguide/vteguide.pdf

http://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/d4b-dvt-bestpractices.pdf

http://www.stoptheclot.org/

http://www.stoptheclot.org/


86

include blood clot education for patients and health professionals, links to news articles, and various events

Venous Thromboembolism (VTE) Risk Assessment (All Patients) Providers can use this VTE risk assessment algorithm from National Health Service (NHS) Choices to assist with VTE risk assessment and to access educational resources for patients and families

Joint Commission VTE 1 VTE measure information form, click on Specifications Manual for National Hospital Inpatient Quality Measures on fist page and then click on Specifications Manual for National Hospital Inpatient Quality Measures v.5.0b. After you download click on the only file showing and find 2j_VTE 1

Venous Thromboembolism Warfarin Therapy Discharge Instructions (CMS VTE-5)

Numerator: Number of patients with documentation that they or their caregivers were given written discharge instructions or other educational material about warfarin

Denominator: Number patients with confirmed VTE discharged on warfarin therapy

Data Sources

Self-Reported


Quality staff

Providers

Pharmacist


Frontline staff


Health Coach


Clinical IT

Nursing Home

Home Care

Hospice


Dietitian

Tips and Tricks

http://healthguides.mapofmedicine.com/choices/map-open/venous_thromboembolism_vte_risk_assessment_and_prophylaxis1.html

http://www.jointcommission.org/venous_thromboembolism/


87

VTE patients with documentation that they or their caregivers were given written discharge instructions or other educational material addressing all of the following: follow up monitoring, compliance issues, dietary restrictions, potential for adverse drug reactions/interactions, activity requirements or restrictions

Include discussion of patients on warfarin therapy at your daily huddles

Ensure that patients discharged on warfarin therapy have a scheduled appointment for an INR prior to discharge

Ensure that patients discharged on warfarin therapy have a scheduled medication management consultation within 7 days of discharge

Resources Joint Commission VTE 5 VTE measure information form, click on Specifications Manual for National Hospital Inpatient Quality Measures on fist page and then click on Download Complete Manual v5.1 2. After you download click on the only file showing and find 2d VTE5 AHRQ Watch the Warfarin! Case Study and best practices for the management of warfarin at hospital discharge

https://www.jointcommission.org/venous_thromboembolism/

https://psnet.ahrq.gov/webmm/case/245


88

Additional Focus Areas (Optional)

Multi-drug Resistant Organism (MDRO) and Antimicrobial Stewardship

Measures

Outcome Measures: Carbapenem-resistant Enterobacteriaceae (CRE) Prevalence

Numerator: Number of LabID CRE events

Denominator: Number of Acute Care Inpatient days

Data Sources

NHSN


Quality staff


Providers

Pharmacist


Frontline staff


Nursing Home

Home Care

Hospice

Lab

Tips and Tricks

Assemble an interdisciplinary team and develop an aim statement that reflects your organization's Antimicrobial Stewardship goals

Educate and ensure that MDRO education is provided at new employee



Participate in the HAI community of practice


Resources CDC MDRO and CDI Module NHSN Multi drug resistant organism & clostridium difficile infection Module



89

CDCs Carbapenem-resistant Enterobacteriaceae Toolkit

Facility Guidance for Control of CRE

Standardized Antimicrobial Administration Ratio (SAAR) Numerator: Number of observed days of antimicrobial therapy reported by a healthcare facility for a specified category of antimicrobial agents used in a patient care location or group of locations

Denominator: Number of days of antimicrobial therapy predicted for a healthcare facility's use of a specified category of antimicrobial agents in a patient care location or group of locations, calculated by applying negative binomial regression modeling to nationally aggregated AU data

Data Sources

NHSN


Quality staff


Providers

Pharmacist


Frontline staff


Lab

Tips and Tricks


Resources

The Standardized Antimicrobial Administration Ratio (SAAR)

CDC development of SAAR, SAAR output options in NHSN and using the SAAR in Stewardship

Standardized Antimicrobial Administration Ratio (SAAR) Table

CDC SAAR Table

Surveillance for Antimicrobial Use and Antimicrobial Resistance Options

CDC Training, Protocols, Data Collection Forms, Supporting Material and Analysis Resources

https://www.cdc.gov/hai/organisms/cre/cre-toolkit/index.html

https://www.cdc.gov/hai/organisms/cre/cre-toolkit/index.html

https://www.cdc.gov/nhsn/pdfs/training/2016/au-saar-vansanten.pdf

https://www.cdc.gov/nhsn/pdfs/ps-analysis-resources/aur/au-qrg-saartables.pdf

https://www.cdc.gov/nhsn/pdfs/ps-analysis-resources/aur/au-qrg-saartables.pdf

http://www.cdc.gov/nhsn/acute-care-hospital/aur/


90

Antimicrobial agent days

Numerator: Number of patient-days when any antimicrobial was prescribed/administered (alone or in combination)

Denominator: Total number of patient days

Data Sources

Self-Reported


Quality staff


Providers

Pharmacist


Frontline staff


Clinical IT

Lab

Resources

CDC Antimicrobial Use and Resistance (AUR) Module Antimicrobial use and resistance requirements and data analyses. Includes antimicrobial groupings for SAAR calculations

Process Measures:

Antibiotic Time Out

Numerator: Number of patients administered antibiotics that have antibiotic "time

out" in order to reassess the continuing need and choice of antibiotics, within 48

hours of initiation of antimicrobial therapy

Denominator: Number of patients prescribed/administered antimicrobial therapy

Data Sources

Self-Reported


Quality staff


Providers

Pharmacist


http://www.cdc.gov/nhsn/PDFs/pscManual/11pscAURcurrent.pdf


91

Frontline staff


Clinical IT

Lab

Tips and Tricks


Ensure that all antibiotics administered in the hospital include an antibiotic time out

Resources

Core Elements of Hospital Antibiotic Stewardship Programs

CDC – Leadership Commitment, Accountability and Drug Expertise, Policies and Interventions, including Antibiotic “time outs”

Antimicrobial Stewardship

By Keith Hamilton, MD, Associate Hospital Epidemiologist, Director of Antimicrobial Stewardship Hospital of the University of Pennsylvania

National Quality Partners Playbook: Antibiotic Stewardship in Acute Care

Leadership Commitment, Accountability, Drug Expertise, Tracking and Monitoring Antibiotic prescribing, use and resistance

http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html

http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html

http://www.hopkinsmedicine.org/armstrong_institute/_files/fellows_course_materials/6_Hamilton_Antimicrobial_Stewardship.pdf


92

Hospital Culture of Safety (Worker Safety) Worker safety is about the health and safety of staff members. Hospitals are one of the most hazardous places to work. Patient lifting, repositioning, and transfers represent some of the most common and preventable sources of injury for employees in the healthcare industry. This is new to the IHC HEN. Measures focus on work-related back injuries, needle-safety and ensuring safe patient handling equipment is available for staff. See below for more detailed information about each measure. The outcome measures will help to determine how many and how often staff members are harmed by safety incidents. The process measure will provide hospitals with a checklist to assist with the ensuring safe patient handling equipment is available, accessible and is in working order.

Measures

Outcome Measures: Work-related Back Injuries

Numerator: Number of work-related back injuries

Denominator: Number of FTEs

Data Sources

Self-Reported


Quality staff

Providers


Frontline staff

Wound/ostomy staff



Lab

Employee Health

Tips and Tricks

Assemble an interdisciplinary team and develop an aim statement that reflects your organization's Worker Safety goals

Educate and ensure that Worker Safety education is provided at new employee




93

Resources

Worker Safety in Hospitals Safe patient handling, understanding the problem Safe Patient Handling- Self-Assessment Busting the Myths Understanding lift equipment Management Support Management, leadership, implementing and assessments Training and Education Training, lift equipment, patient and family, champions and assessments Knowing the Facts Learn from the Leaders Case Studies

Policy and Program Support How to start a policy and a program Program Evaluation Case Studies Effectiveness and Cost Savings Examples, University of Iowa

Needlesticks Numerator: Number of needlestick events

Denominator: Number of FTEs

Data Sources

Self-Reported


Quality staff


Providers

Pharmacist


https://www.osha.gov/dsg/hospitals/

https://www.osha.gov/dsg/hospitals/documents/3.8_SPH_self-assessment_508.pdf

https://www.osha.gov/dsg/hospitals/documents/3.1_Mythbusters_508.pdf

https://www.osha.gov/dsg/hospitals/mgmt_support.html

https://www.osha.gov/dsg/hospitals/education_training.html

https://www.osha.gov/dsg/hospitals/documents/1.1_Data_highlights_508.pdf

https://www.osha.gov/dsg/hospitals/documents/3.6_SPH_profiles_508.pdf

https://www.osha.gov/dsg/hospitals/program_development.html

https://www.osha.gov/dsg/hospitals/program_evaluation.html

https://www.osha.gov/dsg/hospitals/documents/3.5_SPH_effectiveness_508.pdf


94

Frontline staff

Wound/ostomy staff

Lab

Employee Health

Tips and Tricks

Assemble an interdisciplinary team and develop an aim statement that reflects your organization's Worker Safety goals

Educate and ensure that Worker Safety education is provided at new employee orientation and ongoing education throughout the year (Ex. Monthly staff meetings and competency/skill fairs)

Resources

Sharps Safety for Healthcare Settings This safety workbook from The Centers for Disease Control and Prevention (CDC) can help to create or improve an injury prevention program to reduce occupational exposure to bloodborne pathogens

Stop Sticks Campaign The CDC and The National Institute for Occupational Safety and Health (NIOSH) provide information on how to stop sharps injuries. This campaign focuses on empowering healthcare providers and workers to be safe when working around sharps

Workbook for Designing, Implementing, and Evaluating a Sharps Injury Prevention Program This workbook details how to create, improve, and/or evaluate new or current needlestick injury prevention programs

Process Measure: Safe Patient Handling Program Equipment Checklist Compliance

Numerator: Number of units with all checklist items ‘In Place’

Denominator: Number of units assessed

Data Sources

Self-Reported


Quality staff

Providers


Frontline staff


http://www.cdc.gov/sharpssafety/resources.html

http://www.cdc.gov/niosh/stopsticks/

http://www.cdc.gov/sharpssafety/pdf/sharpsworkbook_2008.pdf

http://www.cdc.gov/sharpssafety/pdf/sharpsworkbook_2008.pdf


95

Wound/ostomy staff



Tips and Tricks

Utilize the checklist provided

Begin with one unit and add units to show improvement

Resources

Safe Patient Handling Program Checklist

Training and Education By educating all staff, including providers, about your safe patient handling program, hospitals can reduce instances of a clinician asking or expecting colleagues to move patients in an unsafe way

Management Support One of the most important aspects of any safe patient handling program is support from the top levels of hospital administration. This resource will provide information to help start these conversations Policy and Program Support Safe patient handling policies establish expectations that staff will use the safest techniques to accomplish patient handling tasks, and that administrators will provide equipment and resources to support staff efforts

https://www.osha.gov/dsg/hospitals/documents/3.2_SPH_checklist_508.pdf

https://www.osha.gov/dsg/hospitals/education_training.html

https://www.osha.gov/dsg/hospitals/mgmt_support.html

https://www.osha.gov/dsg/hospitals/program_development.html


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Undue Exposure to Radiation Undue exposure to radiation is avoiding unnecessary testing to reduce exposure to radiation. The measures focus on abdomen CT and thorax CT. See below for more detailed information about each measure. These measures will help to determine how many and how often patients are exposed to undue radiation.

Measures

Outcome Measures: Abdomen CT – Use of Contrast Material (CMS)

Numerator: Number of abdomen CT studies with and without contrast ('combined studies')

Denominator: Number of abdomen CT studies performed (with contrast, without contrast OR both with and without contrast)

Data Sources


Self-Reported


Quality staff

Providers


Frontline staff


HIM

Radiologist

Tips and Tricks

Assemble an interdisciplinary team and develop an aim statement that reflects your organization's Radiation Safety goals

Educate and ensure that Undue Exposure to Radiation Safety education is

provided at new employee orientation and ongoing education throughout the year

(Ex. Monthly staff meetings and competency/skill fairs)

Educate patients and families about radiation safety

Resources

HRET Top Ten Checklist for Radiation Safety

http://www.hret-hen.org/topics/radiation-exposure/HRETHEN_Checklist_Radiation.pdf


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Radiological Society of North America (RSNA) “How I Do It: Managing Radiation Dose in CT” Mayo-Smith, W. W., Hara, A. K., Mahesh, M., Sahani, D. V., & Pavlicek, W. (2014) Radiology Today Choosing Wisely, Imaging Procedures on the Latest List of Ones ‘Patients and providers should question’

Thorax CT – Use of Contrast Material (CMS) Numerator: Number of thorax CT studies with and without contrast ('combined studies') Denominator: Number of abdomen CT studies performed (with contrast, without contrast OR both with and without contrast)

Data Sources

IPOP/Claims data (where available)

Self-reported


Quality staff

Providers


Frontline staff


HIM

Radiologist

Tips and Tricks

Educate patients and families using posters and infographics with helpful information about radiation exposure

Ensure that patients have been evaluated for elevated blood d-Dimer levels and certain specific risk factors before imaging suspected pulmonary embolisms

Educate patients and families about radiation safety

Resources

HRET Top Ten Checklist for Radiation Safety Radiological Society of North America (RSNA) “How I Do It: Managing Radiation Dose in CT” Mayo-Smith, W. W., Hara, A. K., Mahesh, M., Sahani, D. V., & Pavlicek, W. (2014)

http://pubs.rsna.org/doi/pdf/10.1148/radiol.14132328

http://www.radiologytoday.net/archive/rt0413p20.shtml

http://www.hret-hen.org/topics/radiation-exposure/HRETHEN_Checklist_Radiation.pdf



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Radiology Today Choosing Wisely, Imaging Procedures on the Latest List of Ones ‘Patients and providers should question’

Process Measures: Total CT Dose Capture Compliance –Dose Length Product (DLP)

Numerator: Total number of CTs in which the total DLP is recorded

Denominator: Total number of CTs

Data Sources


Quality staff

Providers


Frontline staff

Clinical IT

Radiologist

Resources


Total CT Dose Capture Compliance – Volume CT Dose Index (CTDIvol) Numerator: Total number of CTs in which the total CTDIvol is recorded


Data Sources

Self-Reported


Quality staff

Providers






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Frontline staff

Clinical IT

Radiologist

Resources

Radiological Society of North America (RSNA) “How I Do It: Managing Radiation Dose in CT” Mayo-Smith, W. W., Hara, A. K., Mahesh, M., Sahani, D. V., & Pavlicek, W. (2014) Radiology Today Choosing Wisely, Imaging Procedures on the Latest List of Ones ‘Patients and providers should question’ Total CT Dose Capture Compliance – Size-specific Dose Estimate (SSDE)

Numerator: Total number of CTs in which the total SSDE is recorded


Data Sources

Self-Reported


Quality staff

Providers


Frontline staff

Clinical IT

Radiologist

Resources







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Obstetrical Adverse Events Obstetrical adverse events affect mothers and their infants. The events range from perineal tears to maternal or infant death, leading to extensive hospital admissions and/or neonatal intensive care. All pregnant women and their infants are at risk during labor and delivery. These measures focus on the number of early elective deliveries, uncomplicated primary cesarean delivery rates, peripartum hysterectomy (with and without placenta previa), birth trauma rates, OB trauma (with and without instrument), timely treatment for hypertension, and risk assessment for maternal hemorrhage. See below for more detailed information about each measure.

These measures help to determine how many and how often women are harmed by obstetrical adverse events.

Measures

Outcome Measures: Early Elective Delivery

Numerator: Number of elective maternal deliveries between 37-39 weeks gestation with no medical indication

Denominator: All deliveries between 37-39 weeks gestation

Data Sources


Quality staff

Providers


Frontline staff


Health Coach



Tips and Tricks

Assemble an interdisciplinary team and develop an aim statement that reflects your organization's Obstetrical goals

Educate and ensure that Obstetrics education is provided at new employee




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Hard stop policy in place for EED prior to 39 weeks gestation

Provide education to patients and families

Resources

HRET Top Ten Checklist for OB Harm Top ten evidence based interventions The Joint Commission Joint Commission Performance Measurement FAQs (Click on Performance Measurement FAQs) National Archives and Records Administration – Office of the Federal Register Federal Register, Vol. 77, No. 170/Friday, August 31, 2012/Rules and Regulations. Look to the second column, Page 53528, under (C) “New Chart-abstracted measures: Elective Delivery…” Institute for Healthcare Improvement How-to-Guide: Prevent Obstetrical Adverse Events. Essential elements of prevention, oxytocin bundles, design strategy, forming the team, PDSA worksheet and measurement CDC: Pregnancy Mortality Surveillance System Trends in Pregnancy-Related Deaths

Primary Cesarean Delivery Rate, Uncomplicated

Numerator: Number of maternal inpatients with either MS-DRG code for Cesarean delivery or any-listed ICD-9/10 procedure code(s) for Cesarean delivery without any-listed ICD-9/10 procedure code(s) for hysterectomy

Denominator: Number of deliveries

Data Sources


Self-Reported


Quality staff

Providers


Frontline staff


Health Coach


HIM

http://www.hret-hen.org/topics/ob/13-14/2014-OBHARMChecklist.pdf

https://manual.jointcommission.org/Manual/WebHome

http://www.gpo.gov/fdsys/pkg/FR-2012-08-31/pdf/FR-2012-08-31.pdf

http://www.ihi.org/resources/Pages/Tools/HowtoGuidePreventObstetricalAdverseEvents.aspx

http://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html


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Tips and Tricks

Denominator has specifications: deliveries without previous Cesarean section, abnormal presentation (breech), fetal death or multiple gestation (see technical specifications in AHRQ IQI 33 description)

Review the culture at your hospital, is primary C-section being actively prevented

Be aware of the percentages of Early Elective Inductions that turn in C-sections

Be aware of provider specific commonalitie

Resources

HRET Top Ten Checklist for OB Harm Top ten evidence based interventions Primary Cesarean Delivery Rate, Uncomplicated Technical Specifications – Inpatient Quality Indicators #33 The Joint Commission Joint Commission Performance Measurement FAQs (Click on Performance Measurement FAQs) Institute for Healthcare Improvement How-to-Guide: Prevent Obstetrical Adverse Events. Essential elements of prevention, oxytocin bundles, design strategy, forming the team, PDSA worksheet and measurement CDC: Pregnancy Mortality Surveillance System Trends in Pregnancy-Related Deaths

Birth Trauma Rate – Injury to Newborn (ARHQ PSI 18) Numerator: Number of Newborns with ICD-9/ICD-10 code(s) for birth trauma

Denominator: Number of Newborns

Data Sources


Self-Reported


Quality staff

Providers


Frontline staff



http://www.qualityindicators.ahrq.gov/Downloads/Modules/IQI/V45/TechSpecs/IQI%2033%20Primary%20Cesarean%20Delivery%20Rate%20Uncomplicated.pdf

http://www.qualityindicators.ahrq.gov/Downloads/Modules/IQI/V45/TechSpecs/IQI%2033%20Primary%20Cesarean%20Delivery%20Rate%20Uncomplicated.pdf





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HIM


Tips and Tricks

Denominator excludes preterm infants with birth weight less than 2000 grams, injury to brachial plexus or osteogenesis imperfecta

Delegate the responsibility to review all cases where neonatal injury is present

Be aware of commonalities with types of procedure or provider that result in birth trauma

Be aware of coding errors, are your coders familiar with normal and abnormal findings

Resources

HRET Top Ten Checklist for OB Harm Top ten evidence based interventions Birth Trauma Rate – Injury to Neonate Technical Specifications, Patient Safety Indicators #17 ICD 9/ICD 10 The Joint Commission Joint Commission Performance Measurement FAQs (Click on Performance Measurement FAQs)

Obstetrical Trauma Rate – Vaginal Delivery with Instrument

Numerator: Number of vaginally-delivering, instrument-assisted Moms with ICD9/10 code(s) for 3rd or 4th degree obstetric trauma

Denominator: Number of vaginal deliveries with ICD-9/10 procedure code(s) for instrument-assisted delivery

Data Sources



Quality staff

Providers


Frontline staff


HIM



http://qualityindicators.ahrq.gov/Downloads/Modules/PSI/V50-ICD10/TechSpecs/PSI%2017%20Birth%20Trauma%20Rate%20%E2%80%93%20Injury%20to%20Neonate.pdf

http://qualityindicators.ahrq.gov/Downloads/Modules/PSI/V50-ICD10/TechSpecs/PSI%2017%20Birth%20Trauma%20Rate%20%E2%80%93%20Injury%20to%20Neonate.pdf



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Tips and Tricks


Include your coders

Resources

HRET Top Ten Checklist for OB Harm Top ten evidence based interventions

Obstetric Trauma Rate – Vaginal Delivery With Instrument Technical Specifications, Patient Safety Indicators #18 ICD 9/ICD 10

The Joint Commission Joint Commission Performance Measurement FAQs (Click on Performance Measurement FAQs) Institute for Healthcare Improvement How-to-Guide: Prevent Obstetrical Adverse Events. Essential elements of prevention, oxytocin bundles, design strategy, forming the team, PDSA worksheet and measurement CDC: Pregnancy Mortality Surveillance System Trends in Pregnancy-Related Deaths

Obstetrical Trauma Rate – Vaginal Delivery Without Instrument (ARHQ PSI 19) Numerator: Number of vaginally-delivering, non instrument-assisted Moms with ICD9/10 code(s) for 3rd or 4th degree obstetric trauma

Denominator: Number of vaginal deliveries with ICD-9/10 procedure code(s) for non-instrument-assisted delivery

Data Sources


Self-Reported


Quality staff

Providers


Frontline staff


HIM



http://qualityindicators.ahrq.gov/Downloads/Modules/PSI/V50-ICD10/TechSpecs/PSI%2018%20Obstetric%20Trauma%20Rate%20%E2%80%93%20Vaginal%20Delivery%20With%20Instrument.pdf

http://qualityindicators.ahrq.gov/Downloads/Modules/PSI/V50-ICD10/TechSpecs/PSI%2018%20Obstetric%20Trauma%20Rate%20%E2%80%93%20Vaginal%20Delivery%20With%20Instrument.pdf





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Tips and Tricks


Include your coders

Resources

HRET Top Ten Checklist for OB Harm Top ten evidence based interventions Obstetric Trauma Rate – Vaginal Delivery Without Instrument Technical Specifications, Patient Safety Indicators #19 ICD 9/ICD 10 The Joint Commission Joint Commission Performance Measurement FAQs (Click on Performance Measurement FAQs) Institute for Healthcare Improvement How-to-Guide: Prevent Obstetrical Adverse Events. Essential elements of prevention, oxytocin bundles, design strategy, forming the team, PDSA worksheet and measurement CDC: Pregnancy Mortality Surveillance System Trends in Pregnancy-Related Deaths


http://qualityindicators.ahrq.gov/Downloads/Modules/PSI/V50-ICD10/TechSpecs/PSI%2019%20Obstetric%20Trauma%20Rate-Vaginal%20Delivery%20Without%20Instrument.pdf

http://qualityindicators.ahrq.gov/Downloads/Modules/PSI/V50-ICD10/TechSpecs/PSI%2019%20Obstetric%20Trauma%20Rate-Vaginal%20Delivery%20Without%20Instrument.pdf





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ED Transfer Communication (MBQIP, for applicable facilities) Compliance for each category means all components have documentation in the ED record. Report up to 45 or less (no more) per quarter to meet Rural Emergency Department Transfer Communication measure. To meet HRSA/Flex requirements for MBQIP, report monthly data by expected timeline that is specified on pg. 7 of this document.

ED Transfer Communication Numerator: Number of ED patients transferred to another healthcare facility where all elements were communicated to the receiving facility

Denominator: Number of ED patients transferred to another healthcare facility (Hospice Healthcare Facility, Acute Care Facility (CAH/General Inpatient Care/Cancer/Children's/VA)

Data Sources


Quality staff

Providers

Pharmacist


Frontline staff

Health Coach


Clinical IT

Nursing Home

Home Care

Hospice

Lab


Tips and Tricks

To meet HRSA/Flex requirements for MBQIP, report monthly data by expected timeline that is specified on pg 7 of this document

Compliance for each category means all components have documentation in the ED record. Report up to 45 or less (no more) per quarter to meet Rural Emergency Department Transfer Communication measure

Remember that the “All” category must not be higher than the lowest category

Please direct all questions on MBQIP measures to your Telligen Improvement Advisor, Lori Parsons, email [email protected]

mailto:[email protected]


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Resources QIO Stratis Health Rural EC Transfer Communication Resources

Data specifications manual, action plan, checklists and data collection tool

For the following breakouts, report numerator information matching each area for same

denominator as defined above

I. Administrative Communication

Numerator: Number of ED patients transferred to another healthcare facility

whose medical record documents indicate that all Patient Information (name,

address, age, gender, significant other contact information and insurance

information) was communicated

Data Source:

Self-Reported

II. Patient Information


whose medical record documents indicate that all Administrative Communication

(nurse-to-nurse communication and physician-to-physician communication) was

communicated

Data Source:

Self-Reported

III. Patient Information


whose medical record documents indicate that all Vital Signs (pulse, respiratory

rate, blood pressure, oxygen saturation, temperature and Glasgow Coma

Scale/neuro assessment) were communicated

Data Source:

Self-Reported

IV. Patient Information


whose medical record documents indicate that all Medication Information

(medications administered in ED, allergies and home medications) was

communicated

Data Source:

Self-Reported

V. Patient Information

http://www.stratishealth.org/providers/ED_Transfer_Resources.html


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whose medical record documents indicate that all Practitioner-Generated

Information (history and physical, reason for transfer and plan of care) was

communicated

Data Source:

Self-Reported

VI. Patient Information


whose medical record documents indicate that all Nurse-Generated Information

(nursing assessments/interventions/response, sensory status, catheters,

immobilizations, respiratory support and oral limitations) was communicated

Data Source:

Self-Reported

VII. Patient Information


whose medical record documents indicate that all Tests and Procedures done

and Tests and Procedure Results Sent were communicated

Data Source

Self-Reported