1. Improving Infection Prevention and Antibiotic Stewardship through Quality Improvement Collaboratives: Tales from Two Successful Facilities Featuring: Melanie Brace, RN, Director of Nursing Hancock Park Rehabilitation and Nursing Center, Quincy, MA Sister Katherine Theresa Twitchell, APRN-BC, ANP, Infection Control Marian Manor, Boston, MA Facilitators: Susanne Salem-Schatz, ScD, Collaborative Director Massachusetts Coalition for the Prevention of Medical Errors Laurie Herndon, MSN, GNP-BC, Director of Clinical Quality Massachusetts Senior Care Foundation sss@hcqi.com www.macoalition.org 1

2. History of Massachusetts Learning Collaboratives for Infection Prevention and Antibiotic Stewardship Acute care hospitals: Infection prevention collaborative (2007-2010) C. difficile infection (CDI) Prevention Collaborative (2010-2011) Long term care and cross-continuum: CDI Prevention Partnership Collaborative (2011-2012) Improving Evaluation & Treatment of UTI in the Elderly: a Cross- Continuum Approach to Antibiotic Stewardship (2012-2013) Appropriate evaluation and treatment of UTI in the Elderly (2013-2014) Partners Massachusetts Department of Public Health Massachusetts Senior Care Association 2

3. The Opportunity: Appropriate Evaluation and Treatment of UTI in the Elderly Up to 50% of women in long term care facilities will test positive for bacteria in the urine, and not have a urinary tract infection (asymptomatic bacteriuria). Expert guidelines recommend testing and treating only elderly residents with specific signs and symptoms of urinary tract infection. Even though guidelines strongly advise against treatment, research suggests that up to 80% of people with asymptomatic bacteriuria get antibiotics. Against a backdrop of the crisis of increasing antibiotic resistance, this is an important opportunity to improve quality of care and overall health of nursing home residents. 3

4. Multi-faceted approach Worked with a team of experts in infectious disease, geriatrics and organizational change. Programming that shared evidence about the problem and strategies for improvement. Developed materials to support practice change. Encouraged facilities to create multidisciplinary teams and focus on engaging front line staff in improving care. Offering multiple opportunities for learning (workshops, webinars, coaching calls). Encouraged use of Quality Improvement approaches such as PDSA cycles, or small tests of change. Measurement for improvement and program evaluation.

5. 10/30 Kickoff Workshop 12/4 Webinar Clinical Content Review 12/11 Coaching Call 1/8 Webinar Evaluating altered mental status 2/26,27 Regional workshops focus on engagement strategies 3/14 Webinar Antibiotic stewardship across the continuum 4/12 Coaching, sharing & learning call MEASURE / MONITOR Individual Check-in and Coaching Calls Appropriate Evaluation and Treatment of UTI in the Elderly Collaborative Design (2013-2014: 28 Facilities) 6/17 Closing Workshop Joint focus on evidence, technical improvement and front line engagement

6. Urine Cultures Ordered / 10,000 Resident Days 6

7. Treated UTIs / 10,000 Resident Days 7

8. UTIs Not Meeting Criteria / 10,000 Resident Days 8

9. Why we are here

10. Engaging front line staff: Why it matters 4% known to top 9% known to middle 74% known to supervisors 100% known to the front line & patients Adapted from study conducted by Sidney Yoshida, initially presented at the International Quality Symposium 10

11. 11 TOOLS TO SUPPORT PRACTICE CHANGE

12. Using Measurement for Improvement 12

13. Testing ideas for change: what seemed to work? 13 StudyDo PlanAct AIMS MEASURES CHANGES

14. Hancock Park 14

15. 15 Marian Manor

16. Want to learn more? Tools and Program Materials are available at: www.macoalition.org/uti-elderly-tools Contact us: macoalition@macoalition.org