1. C REATING A C ULTURE OF Q UALITY : Developing the Infrastructure to Meet Quality Improvement Requirements Collaboration Reducing HAI’s Denise VanValkenburgh, RN, BA Liberty dialysis C C Q Creating a Culture of Quality 3/16/2011A renal community collaboration

2. C C Q Creating a Culture of Quality Call to Action! Infections are 2 nd leading cause of death and accounted for 14% of deaths in 2004 Hospitalizations for infections increased 34% between 1993 and 2006 Actual # related to BSI in HD pts is not known but estimated to be 50,000 per year BSIs resulted in 103 hospital admissions /1,000 patient-years USRDS documented 105% increase in total admission for VA infections from 1993-2006 3/16/2011A renal community collaboration

3. C C Q Creating a Culture of Quality Brief History 2002: MMWR: Guidelines for Prevention of IV catheter-related infections 2005: CDC- NHSN (voluntary) 2006: NKF- DOQI Guidelines 2008: HHS/GAO released HCAI in Hospital 2009: HHS Steering Committee for the Prevention of HAI- Second Phase (2009) expanded to include ESRD facilities 2010: Patient Protection and Affordable Care Act 2010: Colorado Dialysis units began reporting DRI to the NHSN; with data being publically reported 2011: Network 3 clinics will being reporting DRI to NHSN 2011: MMWR: Vital Signs: Central Line- ABSI- US 2001, 2008, 2009 3/16/2011A renal community collaboration

4. C C Q Creating a Culture of Quality Liberty Initiatives Collect Surveillance Data on a monthly basis (QAPI at a Glance) Analyze Data and stratify clinics into 4 quartiles Review Data with the Medical Advisory Board (MAB) and develop educational tools to educate professional staff – Work with clinics in the top quartile to identify “best demonstrated practices” – Work with clinics in the lower quartile to improve performance Collaborate with Oversight Agencies (CMS/Networks) to improve facility level performance 3/16/2011A renal community collaboration

5. C C Q Creating a Culture of Quality Next Steps? Educate community on ‘new’ terminology – HAI-CLABSIs-LAI-AAB Standardize data analyzes/comparison – USRDs reports ‘patient-years’ – NHSN reports ‘patient-months’ – MMWR refers to ‘patient-days’ – Literature reports data in multiple ways Coordinate facility level activity with Corporate offices Sensitivity to time commitment of local data collection efforts 3/16/2011A renal community collaboration