1. Ventilator-Associated Pneumonia K-HEN Data Collection & Submission Dolores Hagan, RN BSN K-HEN Education and Data Manager August 2012

2. Objectives Review reporting requirements Review K-HEN recommended measures Review the specifications for monitoring data (Inclusion and exclusion criteria) Discuss requirements for baseline data Define data entry and submission timeline Identify measures that may be pulled from other systems where data is currently being entered 2

3. Reporting Requirements For each topic area chosen, hospitals are required to submit data for at least – One process measure AND – One outcome measure Hospitals are strongly encouraged to report on the K-HEN recommended measures Additional outcome and/or process measures may be selected and reported as desired 3

4. K-HEN Recommended Measures Purpose—standardize reporting on the same measures across the state for robust benchmarking capability Measures selected based on polling data from the KHA Quality Conference in March 2012 Have continued to evolve with your feedback (Keep it coming! ) 4

5. HRET HEN Encyclopedia of Measures Lists all measures available in the CDS Defines the numerator and denominator for each measure Provides a link to the source of the measure http://www.k- hen.com/Portals/16/Documents/HRET_HEN_ Encyclopedia_of_Measures_v3.pdf http://www.k- hen.com/Portals/16/Documents/HRET_HEN_ Encyclopedia_of_Measures_v3.pdf 5

6. VAP: Outcome Measure Preferred measure: #92 or 95 ICU or High Risk Nursery (HRN) Ventilator-associated pneumonia rate (ventilator days denominator) Alternate measure: #93 or 94 All non-ICU units or all units, ventilator-associated pneumonia rate (ventilator days denominator) 6

7. # 92 or # 95 VAP Criteria Numerator—The number of ventilator- associated pneumonia in ICU or HRN Denominator—Number of ventilator days (collected daily) – #92—ICU ventilator days – #95—HRN ventilator days Equation—(Number of VAP/Number of ventilator days in specified unit) * 1000 7 Source: CDC NHSN

8. # 93 or # 94 VAP Criteria Numerator—The number of ventilator- associated pneumonia within the specified unit or units Denominator—Number of ventilator days within the specified unit – #93—All non-ICU units patient days – #94—All units Equation—(number of VAPs in specified units/number of ventilator days in same specified units)*1000 8 Source: CDC NHSN VAP

9. VAP: Process Measure Preferred Measure: #90 Ventilator Bundle Adherence Rate Alternate Measure: #91 Hand hygiene adherence rate (VAP) 9 Source: CDC NHSN & Joint Commission Hand Hygiene Reference

10. #90 Ventilator Bundle Use Criteria Numerator—Number of patients on mechanical ventilation at the time of survey for whom all four elements of the bundle are documented in place. HOB elevation ≥ 30 degrees or contraindication; noted on 2 different shifts within a 24-hour period Daily sedation interruption and assessment of readiness to extubate; complete documentation required Peptic ulcer disease prophylaxis DVT prophylaxis Denominator—Total number of patients on ventilators at the time of observation 10 Source: NQF Ventilator Bundle Use

11. #91 VAP Hand Hygiene Compliance Numerator—Hand hygiene performed consistent with guidelines Denominator—Total number of hand hygiene observation opportunities Equation—(Total number of acts of hand hygiene consistent with guidelines/total number of observed hand hygiene opportunities) X 100 11 Source: Joint Commission Hand Hygiene Reference

12. Baseline Data Only submitted one time For all topic areas except Readmissions: – Baseline data is from 2011 prior to January 1, 2012 – May be the entire calendar year of 2011 or any other period within the year (a month, a quarter, etc) – Enter your specific period beginning and ending dates Readmission Baseline Data – Preferably CY 2011 – May use Jan – Jun 2012 if 2011 data is not available If no baseline data is available, do not enter anything for baseline—begin with monitoring data 12

13. VAP Baseline Data Complete baseline data entry by August 15! NHSN data will be extracted once rights are conferred Data should be entered on a monthly basis as much as possible 13

14. 2012 VAP Monthly Data Entry Schedule Monitoring MonthData Entry AvailableData Entry Complete JanuaryImmediatelyAs soon as possible* FebruaryImmediatelyAs soon as possible* MarchImmediatelyAs soon as possible* AprilImmediatelyAs soon as possible* MayImmediatelyAs soon as possible* JuneImmediatelyAs soon as possible* JulyAugust 1, 2012August 31, 2012 AugustSeptember 1, 2012September 30, 2012 SeptemberOctober 1, 2012October 31, 2012 OctoberNovember 1, 2012November 30, 2012 NovemberDecember 1, 2012December 31, 2012 DecemberJanuary 1, 2013January 31, 2013 14 *If data is available

15. Comprehensive Data System (CDS) Link to HRET training webinar for CDS located on K-HEN website under Data Page https://www.hretcds.org/Login.aspx Data coordinator receives initial login and creates hospital’s users – At least two data administrators – As many data entry users as needed 15

16. Measure Selection Review the K-HEN Recommended Measures and the HRET Encyclopedia of Measures Determine which measures you will report Remember you MUST report on at least one process and one outcome measure per topic area selected 16

17. Measure Enrollment Enroll in the measures that you are reporting Select Admin  Measure Enrollment – Select the topic area – Select/deselect and save the measures that you will be reporting on – This will narrow your choices for data entry to only those selected – You may reselect those measures at a later time if desired 17

18. Data Collection & Entry Review the numerator and denominator criteria for the measures selected Collect and compile the data Sign on to the CDS – Select Data Entry tab – Select the topic from the drop  Select Next – Find the appropriate measure  Select Enter Data 18

19. Baseline Data Entry Defaults to the Baseline tab Enter the Measurement start and end dates  Select ‘Add’ Under ‘Data Entry’ column, Select ‘Go’ Was data collected for this measurement period?  Select Yes or No – If No, enter reason (e.g. data not available) – If Yes, enter the numerator and denominator – Select Save or Submit Save holds data in ‘temporary’ area and is not available for reporting within the CDS Data may be edited by the hospital until it is submitted 19

20. Monitoring Data Entry Select the Monitoring tab Under the Data Entry column, Select ‘Go’ for the appropriate month Was data collected for this measurement period?  Select Yes or No If No, enter reason (e.g. data not available) If Yes, enter the numerator and denominator Select Save or Submit – ‘Save’ holds data in ‘temporary’ area and is available for reporting within the CDS – Data may be edited by the hospital until it is submitted 20

21. Data Tidbits Each month should have data entered or a reason it was not collected Additional training will be provided after data has been entered and reporting is available 21

22. Monthly Progress Report Due to K-HEN by the 10 th of each month Use template provided One report per topic area Report template and sample complete report located on K-HEN website (www.k- hen.com) under Tools and Resourceswww.k- hen.com 22

23. Aim?: (Including your How Good and By When statement) Why is this project important?: Aim Statement Changes being Tested, Implemented or Spread Recommendations and Next Steps Lessons Learned Run Charts (For each listed change, indicate whether it is being tested (T), Implemented (I) or Spread (S)) (Enter summary here) Enter summary here (what do you need from Executive Project Champion, Sponsor at this time to move project?) Recommendations Next steps for testing Project Title: ______________________________ Date: _____________ Hospital Name: ____________________________ State: _____________ © 2012 Institute for Healthcare Improvement Team Members (Name of Project Champion, Senior Leader Sponsor & all other names & roles) (Make fonts large, title, labels, dates and notes very simple on graphs prior to shrinking graphs. Should be able to fit 6-8 readable graphs here. If no data are available for a particular measures either create “empty” run list the name of the measure(s) to be collected.) Self Assessment Score, 1-5 (see AHA/HRET Assessment Scale document) = Self Assessment Score, 1-5 (see AHA/HRET Assessment Scale document) =

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25. Project Assessment Scale http://www.k- hen.com/Portals/16/Documents/HRETHEN ProjectAssessmentScale.pdf http://www.k- hen.com/Portals/16/Documents/HRETHEN ProjectAssessmentScale.pdf 25

26. Homework Set up CDS users for your site Collect and enter baseline data by Aug 15 Enter monitoring data for Jan - Jun 2012 as available and time permits Enter monitoring data for Jul 2012 by Aug 31 Complete July progress report by Aug 10 and email to info@k-hen.cominfo@k-hen.com 26

27. Questions 27