1. Shared Learning for Infection Prevention
THA Collaborative on
Reducing HAIs
August 2008
Tori Howk, Director of Risk and Regulatory
Thank you, Darlene
Good morning everyone.
My role
17 hospitals in KY, TN, and north Georgia.
See ____________patients

2. Collaborative Aims Improve the culture of safety
Reduce patient harm by reducing CLBSI
MRSA
25% reduction in surgical complications by implementing SCIP
Whatever we do, we want to do it the best way we can. For you, that may be raising family, hobby, or at work in the hospital or other healthcare organization.
And when you go about that activity, you look to others for advice, ideas, best practices, outcomes?
Not an IC expert. Come to you in the name of sharing.
Improvement and sharing: Part of the job I love.
Culture – manner in which we go about this. The environment, norms, expectations, and history.
Reduce harm: Not just because CMS, TJC, Leapfrog, NQF, CDC, etc., Something to do with your relatives, my family, and our friends.
So to do this, it takes a team. Teamwork, might be overstated, but still critical. We are in this together!
THA – August 2008

3. New Name for ICP Infection Preventionists
“The term infection preventionist clearly and effectively communicates who our members are and what they do.
Infection Preventionists develop and direct performance improvement initiatives that save lives and resources for healthcare facilities, so this was a natural transition – or a right-sizing of the name – to more accurately reflect their role.”
Congratulations to the ICP’s. Now “preventionists” per APIC.
Previously it was the Infection Control Nurse, IC Coordinator, IC Practitioner, now this is more fitting. Tremendous undertaking and responsibility to reduce infections in an organization.
Responsible to develop and direct PI activities to save lives
THA – August 2008

4. Improvement Opportunity
$5 billion to US healthcare costs every year
1.7 million hospital-acquired infections in 2002 associated with 99,000 deaths
“Research has shown that hospitals are not following recommended guidelines to avoid preventable hospital-acquired infections.”
87% of hospitals completing Leapfrog survey do not follow recommendations to prevent many of the most common hospital-acquired infections.
How BAD is this, and why are we in this situation?
CDC estimates that $5billion to US healthcare costs every year…Much greater impact now.
“Not following recommendations”, CMS in their HAC transmittal a couple weeks ago
“Not following recommendations”, Leapfrog
Information is out there. Amazed at the volume of material, evidence, and “case” for improvement. Haven’t adopted them quickly enough.
Why? Because it’s difficult to keep up. Not b/c don’t know or don’t care. Complex inter-woven systems and processes involved.
Humans – want to do a good job, but distracted, forget, tired, I do it differently, no standard process or systems to support that.
THA – August 2008

5. Benefits of Reducing Infections
Better patient outcomes
Reduced mortality
Improved satisfaction
Physician
Nursing
Patients and families
Financial benefits
So this is WHY we need to improve.
For clinical reasons obviously, but also the business case for Infection Control to reduce infection.
Through core measures, we have seen a willingness to support the business case for Quality.
Why we’re going to do it
THA – August 2008

6. Bundle
…“is a group of interventions related to patients with intravascular central catheters that, when implemented together, result in better outcomes than when implemented individually.”
2005 Institute for Healthcare Improvement
HOW we can do it
IHI defines a “bundle”, like Central Lines. For infection prevention, substitute a group of strategies related to infection prevention, when implemented together, result in better outcomes than when implemented individually.
The combination of various tools, techniques, related systems, that create the improvement.
Orchestra, a clarinet, while a lovely sound, contributes far more as part of the ensemble than alone.
We will talk about a multi-pronged approach we undertook (underTAKING) to improving systems and processes, and thus results.
THA – August 2008

7. What Are Hospital Acquired Conditions? (HAC)
Section 5001(c) of the Deficit Reduction Act (DRA) of required the Secretary of the Department of Health and Human Services to select at least two conditions that are: (1) high cost, high volume, or both; (2) identified through ICD-9-CM coding as a complicating condition (CC) or major complicating condition (MCC) that, when present as a secondary diagnosis at discharge, results in payment at a higher MS-DRG; and (3) is reasonably preventable through application of evidence-based guidelines.  
Last year, CMS selected eight conditions for the HAC provision. 
Beginning October 1, 2008, Medicare will no longer pay at a higher weighted MS-DRG for the original eight conditions plus three, as well as any conditions CMS is proposing to add in this year’s rule. (5 HAIs)
The HAC listing, out this year & recently updated for new hospital acquired conditions.
Medicare will no longer pay the higher weight DRG if is identified through coding as a CC.
Rate adjustment for Hospital-Acquired Condition payments
CMS will then collect, compare, and display HAC rates
THA – August 2008

8. Hospital-Acquired Conditions (HAC)
Never Events/Rare Occurrences
Patient Safety
Infection Prevention
Delivery of ABO-Incompatible Blood
Falls and fractures, dislocations, intracranial and crushing injury and burns
Surgical Site Infections - Mediastinitis after coronary artery bypass graft (CABG) surgery - Orthopedic surgeries - Bariatric surgery
Objects left in during surgery
Pressure Ulcers
Vascular catheter-associated infections
Air Embolism
Glycemic Control
Catheter-associated urinary tract infections
Pressure Ulcers/DVT
By Category
Infection Prevention last column, highlighting 3 major areas and 5 conditions.
3 of which are specific surgery types
THA – August 2008

9. TriStar Shared Learnings
MRSA
Central Line Bloodstream Infections
SCIP
So the opportunity for Infection Prevention is deep and wide.
For MRSA, Central Line BSI, and SCIP, I will share some approaches that we have found effective in our company, in our division, and in our hospitals.
Shared learning.
THA – August 2008

10. Improvement Triad THA – August 2008
Leadership – about culture and expectations.
Friend…Fish rots from the head down. Leadership is essential.
Sets the tone, provides direction and resources, supports the work of the subject matter experts.
Systems and Process Improvements
Anytime the process is standardized, the risk of error decreases. Still humans, and there will be risk of error (or noncompliance), but it will be minimized.
Make it easy to do it right and hard to do it wrong.
Measurement and Feedback
We improve what we measure. Need feedback; want feedback; perpetuates the improvement cycle. Also readjusting.
THA – August 2008

11. Approach Understand the opportunity Collaborative Improvement
Literature search
Assess current performance metrics and practice (Gap Analysis)
Collaborative Improvement
Identify best practices
Refine tools and systems based on Gap Analysis
Test improvements
Shared Learning
Deploy toolkits, checklists, policies, resources, supply recommendations, education modules, system enhancements
Metrics Review
The basic process improvement is essential.
It is an approach to improving, tried & true PI model.
Opportunity:
Determine where your performance is now
Establish the priorities
Colllaboration:
Develop a team of individuals who have the knowledge, skills, and abilities to facilitate change. Compare current practice with science. Research “smart people”.
Understand the evidence and literature
Share
Implement the changes
Change is hard; people get into habits. If can recognize the need for change, can believe in it, work through it, support it, and sustain it.
Measure
Celebrate
Complex set of initiative such as these, stick to the plan. Don’t forget any step of this.
Cycle
1Gap Analysis
Conduct gap assessment of current practice
Completed accurately and verified
Identify gaps
Individualize project plan based on gaps
Update project plan based on results
Specific tasks for HAC
MD education or awareness
MEDITECH documentation implementation
Changes to supplies
Implementation of protocols
Facility-Defined Action Plan for HACs with Gaps
Revise policies, procedures, competencies, etc.
Educate staff on changes
Implement changes
Other tasks as identified by facility
Effectiveness monitored by POA report and ongoing reviews
Carefully read the guidance documents and resources
Compare and assess hospital’s process and protocol to the guidance documents, and revise as necessary
Revise related clinical practices as needed
Raise hospital and medical staff awareness of the risks and evidence-based prevention strategies through education
Revise/implement forms and documentation tools as needed
THA – August 2008

12. Death and complications MRSA among most common and problematic of HAIs
50% post surgical infections for CABG and orthopedic prosthetics
Excess costs
Malpractice claims
Proven strategies to reduce or nearly eliminate nosocomial MRSA
HCA
Same message with all
Costs (human, economic, and society)
Preventable
Evidence published to prevent
THA – August 2008

13. Active Surveillance (Systems/Processes)
Active Surveillance, the first system and process change
THA – August 2008

14. Active Surveillance High Risk Patient Screening
Previous MRSA history
Preoperative Screens
Total hip
Total knee
Open spine procedures
Cardiac surgeries
Private rooms, cohorting, and isolation
ICU admissions/transfers
Outborn transfers to NICUs
Long term care facility admissions
Hemodialysis admissions
Process changes involving Admissions, Infection Control, Surgery, ICU/Nursing, Physicians
THA – August 2008

15. Barrier Precautions THA – August 2008 Barrier Precautions – not new
Signs placed
THA – August 2008

16. Barrier Precautions Standard precautions for all patients
Contact isolation of positive patients
Personal protective equipment
Gown
Gloves
Mask with shield
Dedicated equipment
Ticketing for non compliance
THA – August 2008

17. Compulsive Hand Hygiene
Signage at doors, patient care areas, brochures, letters to patients
THA – August 2008

18. Compulsive Hand Hygiene
Expectation of 100% compliance with soap and water or other hand hygiene products
Vendor assistance with alcohol gel strategy
Patient encouraged to question hand hygiene practices of caregiver
Staff pledge
THA – August 2008

19. Disinfection/Environmental Cleaning
Great work with EVS
Specialized education
THA – August 2008

20. Disinfection/Environmental Cleaning
Proper disinfection techniques Proper supplies
Proper equipment
Environmental services education
Workload analysis
Observation for adherence
THA – August 2008

21. Executive Ownership/Leadership
Executive and Physician Champions
Interdisciplinary taskforce
Executive walk arounds
Medical Executive Committee engagement
MEC and Board reports
Recognition and reward
THA – August 2008

22. Campaign Executive messaging Collaborative calls
Patient/visitor information cards
Banners, posters, buttons, static clings
Waterless sanitizer/soap dispenser signage
Isolation signage
Staff newsletters
Electronic triggers and trackers
THA – August 2008

23. Campaign
Target audience--patients, caregivers, physicians, non-clinical staff, visitors, volunteers, vendors
Community collaboration—EMS, local health department, other healthcare providers
Data collection, analysis, and dissemination
Clean hands are cool hands site and campaign for kids
THA – August 2008

24. Measurement - 2007 MRSA Swabbing Rate
Original goal was 80%
THA – August 2008

25. 2008 MRSA Swabbing Rate
Goal of 90%
THA – August 2008

26. THA – August 2008

27. THA – August 2008 How long implemented
We knew from those we caught on the front-end that we would impact MRSA and decrease risk of transmission.
Study / results?
THA – August 2008

28. Central Line Infections
Prolongation of hospitalization: days
Cost to healthcare system: $33,000 - $35,000/episode
Attributable mortality: 12-25%
Same message:
Cost
Preventable
Evidence – slow to adopt
THA – August 2008

29. Central Line Bundle Hand hygiene Maximal barrier precautions
Chlorhexadine skin antisepsis
Optimal catheter site selection, with subclavian vein as the preferred site for non-tunneled catheters in adults
Daily review of line necessity with prompt removal of unnecessary lines
You are familiar with this
THA – August 2008

30. CLBSI System/Process Improvement
Healthcare worker education
Hand hygiene
Practice guidelines/IHI Bundles
Checklist pocket reminders
Medical staff education on bundles
Checklists for line insertion
Surveillance rates to determine current performance
TriStar examples
Checklist computerized now, previously paper tool or poster
THA – August 2008

31. CLBSI System/Process Improvements
Supply Chain
Evaluation of all kit components for chlorhexadine
Drape and barrier availability through supply chain and all-inclusive carts
Computer screen standardization
Checklists on screen (or paper)
Daily site surveillance review of necessity added to flowsheet
THA – August 2008

32. CLBSI Measurement and Feedback
Computer screen standardization
Automatic capture of data for documentation and data collection
Physician documentation tools
Insertion observation
Performance feedback
THA – August 2008

33. Central Line Insertion Monitor
DATE:________________
PHYSICIAN INSERTING:_____________________________
SITE:  IJ  Subclavian  PICC  Femoral
 NOTE: PICC or SUBCLAVIAN sites preferred. If not utilized, must document justification for utilizing another site. 
 Morbid Obesity  Respiratory Condition Prohibiting  Emergency
_______________________________________________________________________
 HAND HYGIENE performed by MD and Assistants?
 MASK worn by MD?
 STERILE GOWN worn by MD?
 STERILE GLOVES worn by MD
 LARGE STERILE DRAPE used?
 CAP worn by MD?
 CHLORAPREP used? Back and forth motion for 30 seconds/allow to dry for 30 seconds
 OTHER PREP used? If “Y”, explain:
 CXR Ordered/Completed?
Nurse:___________________________________________________
 REMEMBER: Nurse must document ALL Vascular Line STARTS on IV Screen!
Observation – 100%
Nurse pulls out form
THA – August 2008

34. SCIP
Among patients admitted for surgery, SSIs account for 38% of hospital-associated infections
Emori & Gaynes, Clinical Micro Reviews, 1993
On average, SSI results in 7.3 excess hospital days and adds $3150 to cost of hospital care (1992 dollars)
CDC, MMWR, 1992
Cost of treatment for an SSI associated with total joint replacement (hip or knee) is $50,000
Hanssen AD et al, J Bone Joint Surg Am, 1992
Significant financial, resource, and human costs
THA – August 2008

35. 2nd highest adverse event
THA – August 2008

36. SCIP National Quality Measures
SCIP 1 Prophylactic antibiotic received within one hour prior to surgical incision
SCIP 2 Appropriate prophylactic antibiotic selected for surgical patients consistent with current guidelines
SCIP 3 Prophylactic antibiotic discontinued within 24 hours after the end of surgery (within 48 hours after the end of surgery for CABG or other cardiac surgery)
SCIP 4 Cardiac surgery patients with controlled 6 A.M. postoperative blood glucose < 200mg/dL on Post Op Day 1 AND Post Op Day 2
SCIP 6 Surgery patients with appropriate hair removal
SCIP 7 Colorectal surgery patients with immediate postoperative normothermia > 98.6*F within first 15 minutes after leaving OR
Company
Division
Facility-specific
Toolkits, shared sites, signage
THA – August 2008

37. SCIP Leadership & Responsibility
Surgical services director may be a logical leader for SCIP compliance throughout the facility (IC, Quality)
An executive sponsor is needed to support the director in implementing changes
A physician champion, surgeon or anesthesiologist, is needed to assist with education and address physician practice issues.
The quality director should provide frequent updates on performance and opportunities for system and process improvement
Move to first
Champion for CLBSI and MRSA, too.
Someone needs to “own” it, knowing it will be a team activity
Leadership is key, nothing will happen without that. Message, visibility, resources, removing barriers, and acknowledge progress
MD / Surgeon champion is key. Change is not their friend.
Quality source for improvement, data, and compliance
THA – August 2008
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38. SCIP System/Process Improvements
Evidence-based order sets
Preprinted, service-specific preprinted orders
Preop and post-op
Antibiotic dosing charts
Communication
Scripted time-out poster
Hand-off
Pharmacy notice of close time, times next dose(s)
Antibiotic dosing
IT Screens
Prompts, reminders, required fields, inclusion of antibiotic administration in OR nursing documentation (IV unless otherwise)
Positive DVT screen, then auto-printing of pre-printed order
THA – August 2008

39. Improvement through IT System
Core Measures are embedded in the following screens*:
Pre-op Prep
Pre-op Outcomes
Intraoperative RN Checklist and Assessment
Intraoperative Prep
Intraoperative RN Outcomes
PACU Admission Assessment
PACU Outcomes
* Screens reflect core measures for discharges effective 10/01/07 to 3/31/07. Core measure screens will be updated as data elements change. SCIP Core measure related queries are worded EXACTLY as defined by National Hospital Quality Measures.
THA – August 2008

40. Screen Example
Tremendous support from IT (Division – facility).
Meets with users and key stakeholders (Pharmacy, IC, Falls team, RT, Nursing)
Working currently on HAC screen modifications
If razor is selected for hair removal method, a “pop-up” box will appear for the nurse to confirm that razor is the accurate response.
THA – August 2008

41. Education
SCIP Measures Poster
Sample
THA – August 2008
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42. Checklists Time Out Poster THA – August 2008 42 Checklists
Human Factors previous work
Retained foreign body
Pre-procedure time-out
THA – August 2008 42

43. SCIP Improvement Tactics
System/Process Improvement Tactic
Measures Impacted
Evidence based order sets
(Pre-operatively & Post-operatively)
SCIP 1, 2, 4, 7
SCIP VTE 1, 2
Antibiotic dosing chart and selection chart
SCIP 1,2,3
Computer screen standardization
SCIP 1,2, 6,VTE 1, VTE 2, CARD 2
VTE mechanical and chemical prophylaxis chart
SCIP VTE 1, VTE 2
Pharmacy review of medication orders
SCIP 1, 2, 3, 4,VTE 1, VTE 2, CARD 2
Summary grid of improvement tactics
THA – August 2008 43

44. SCIP System/Process Improvements
Education and Competency
Clinical Staff
Physician
Abstractor
Worksheets
Standard Order sets
IT Screens
Core Measures designated “bulleted” on order sets
Pharmacy interfaces (close time report)
Webcasts
CBT
Just-in-time reminders
Executive walk-arounds
Order sets to prompt physicians
“I’ll do anything; just prompt me along. I can’t keep up with it all.” Core measures change too much.
IT screens to guide clinicians and also capture data
Bulleted with blue ribbon on order sets
Pharmacy involvement. Close time prints on one report, scanned to Pharmacy, movement of patient to the floor. Sets antibiotic d/c time
THA – August 2008

45. Core Measure Concurrent Management
Core measure checklist on charts
Interact with physicians & staff
Preview OR schedule
Presence in PAT, PACU, and floor
Debriefing forms
Form
Abstraction tool
Applicable portion of medical record
Routed/reviewed with Clinical Service Director
Real-time understanding of process and opportunities
Clinical director for employee and/or MD
Hospitalist coordinator for MD
Talk about “relationships”. The quality of the product (or service) is directly proportional to the quality of the relationship involved between those who create it.
You can see it.
THA – August 2008

46. Concurrent Abstraction
Real-time opportunity to improve
Feedback
Within 7-10 days
Correlation with improved performance
Abstraction
Into Vendor System
Into Clinical Documentation System
Rolls into Vendor system
Into Quality Management Module
3 days for bill to drop
Data pulled from Coding System
Compared to coding guidelines for HAC
Sent back out to hospitals
SPAE
THA – August 2008

47. Measurement and Feedback
Performance
Employee
1:1
Director
Physician
1:1 (verbal or written)
Hospitalist Coordinator
Medical Director
Ongoing Professional Practice Evaluation/Profile
Peer Review?
Incentive Plan
Profile for Ongoing Professional Practice Evaluation (OPPE)
Medical Director or Clinical Service Director
Department, Facility, and Division Comparison
THA – August 2008

48. Measurement and Feedback
Weekly Core Measure Meetings
Laptop with system access
Review rationale, record, TJC,
Directors of clinical services (ED, Ph, ICU, Nsg, OR, ER, Q, CNO, Hospitalist Coord.)
Current outliers
Export to EXCEL – to director of that area, dates, MR#, during meeting
Follow-up on previous and new outliers
Facility Feedback
Routinely at all meetings (Department, Quality, MEC, Board)
Division
Weekly metrics
Quarterly/annual trends and comparisons
Show why didn’t meet
Homework
Followup with old and then new one
Bottom line: a living priority, active management, intimate knowledge of the process and the people doing that. “dog it”
THA – August 2008

49. Important to Remember…
Core measure requirements are revised and changed every April and October.
Be sure you get the updates and change your practice accordingly.
These measures are evidence based and as the evidence changes and progresses, so do these measures.
Ultimate in continuous improvement cycle.
The consummate improvement initiative.
Constant, targets moving,
everyone is getting better, entire team,
leadership priority,
stakeholders recognize quality and the return, CFO $ & Core measures?
continual cycle of evaluating current performance,
understanding opportunities and “misses”,
implementing changes,
leading the change, re-evaluating, etc.
THA – August 2008 49

50. TriStar Division Measurement
Metrics
MRSA Reports
HAC Reports
Hand Hygiene
Concurrent management
Concurrent abstraction
Weekly metrics
QOR Review
QM review screens
Collaborative
Don’t reinvent the wheel
Familiar
Visible
High-profile from employees to leaders, physicians, and Division leaders
What gets measured gets improved
THA – August 2008

51. Every Monday
To everyone
Comments
THA – August 2008

52. New HQC
From Coding system, using coding guidelines and ICD9 codes
THA – August 2008

53. Improvement Triad THA – August 2008 Again…
Leadership – about culture and expectations.
Leadership is essential.
Sets the tone, provides direction and resources, supports the work of the subject matter experts.
Systems and Process Improvements
Anytime the process is standardized, the risk of error decreases. Still humans, and there will be risk of error (or noncompliance), but it will be minimized.
Make it easy to do it right and hard to do it wrong.
Measurement and Feedback
We improve what we measure. Need feedback; want feedback; perpetuates the improvement cycle. Also readjusting
Measurement. Leadership, critically important. Serious role being responsible for the heatlhcare outcomes of those who come to us trusting for safe and effective, and compassionate healthcare.
One of our leaders is so passionate about this professional responsibility…
THA – August 2008

54. Measurement / Celebration
All “green”
Weekly!
Personal responsibility… anything more personal than your hair?
Especially the “color”?
THA – August 2008

55. Measurement THA – August 2008 Yellow and green
An “opportunity for improvement”
Red?
THA – August 2008

56. Steps
Leadership must understand where you are and what the improvement opportunity is
Thoroughly understand the evidence behind the clinical care recommendations
Flowchart to clearly understand the current clinical practice to determine gaps between care and EBM
Deliver clinical care message at facility staff and physician staff meetings
Include data that illustrates where hospital stands in current performance
Improve systems and processes through adoption of evidence - based practices (tools, policies, orders, algorithms, systems)
Revise forms and processes to implement practices from high-performing facilities
Meet individually with physicians that have specific concerns
Measure performance and provide feedback
Circle goes around, never-ending, 100% reliable healthcare
THA – August 2008 56

57. THA – August 2008 Just when you think you aren’t going to make it.
You can’t handle one more CMS transmittal, core measure change, or external source for advice…
You can.
Because…
THA – August 2008

58. Shared Learning for Infection Prevention
Thank You!
Shared Learning for Infection Prevention
THA Collaborative
August 2008