ahrq safety program for long-term care: hais/cauti cohort 4 june 3, 2015 health research &...
TRANSCRIPT
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AHRQ Safety Program for Long-term Care: HAIs/CAUTI
Cohort 4
June 3, 2015
Health Research & Educational Trust
Project Team Members
Facility Informational Webinar
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Agenda
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Topic PresenterWelcome and Project Overview Marcia Cooke
Achieving Project Goals Amanda Wilkins
Measuring Success A.J. Rolle
LTC Facility Team Lead Role Louella Hung
Timeline & Next Steps Helen Plass
Question & Answer All Attendees and Presenters
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PROJECT OVERVIEW
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Marcia Cooke, RN-BC, MSN, PhD
Director, Clinical Quality at HRET
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Objectives
• Recognize project goals and why the project matters
• Identify the approach to education, coaching and measuring progress
• Summarize Facility and Facility Team Lead responsibilities
• Describe how HRET and the National Project Team will support facilities
• Recall upcoming key dates
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Partnerships & Dissemination
Nat iona l Pro jec t TeamHRET UM Abt Qualidigm APIC SHM Baylor
Nat iona l Pro jec t TeamHRET UM Abt Qualidigm APIC SHM Baylor
State or Regional Lead Organizations, Multi-Facility
Operators
State or Regional Lead Organizations, Multi-Facility
Operators
FacultyFaculty
Organizational Leads
Recruitment/Coaching/Project Liaison
Organizational Leads
Recruitment/Coaching/Project Liaison
National & Regional Faculty UM, Abt, Qualidigm, APIC,
SHM, Baylor
Coaching/Endorsement
National & Regional Faculty UM, Abt, Qualidigm, APIC,
SHM, Baylor
Coaching/Endorsement
FacilitiesFacilities
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AHRQAHRQ
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Causes of Re-hospitalizations from LTCFs
Top reasons for readmission from LTC facility to a community hospital:
a. CHF 31%
b. UTI 28%
c. Renal Failure 27%
d. Pneumonia 23%
e. COPD 23%Source: Ouslander JG. Journal of the American Medical Directors Association, March 2011.
“CHF, respiratory infection, UTI, sepsis, and electrolyte imbalance account for 78% of 30 day rehospitalizations from SNFs”
Source: Unpublished MedPAC data cited by Mor V. Health Affairs, January 2010
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Why This Project Matters
• 1-3 million serious infections annually in LTC facilities• Approximately 380,000 residents die of infections each year• Urinary Tract Infection is one of the most common HAls in LTC facilities• Infections are among the most frequent causes of transfer & readmissions from
LTC facilities to acute care hospitals• High prevalence of urinary catheters in hospital patients transferred to LTC facilities
Improving safety and quality of life for residents and their families is our overall aim!
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What’s in it for LTC Facilities?
• Improved care and resident/family satisfaction • Alignment with CMS 11th SOW/QAPI and Advancing Excellence• Apply evidence-based train-the-trainer modules to strengthen front-line staff
knowledge and skills on infection prevention• Earn CNE credits• Avoid penalties for violations of F 315 (unnecessary urinary catheter) and F 441
(infection prevention and control)• Reduced staff workload burden• Maintain higher census from lower mortality, hospitalization• Prepare for value-based purchasing
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How will LTC Facilities Benefit from Participation
Potential to:• Improve the Nursing Home Compare Quality Measures• Enhance data collection skills and prepare for mandatory reporting of infection
data (NHSN)• Benchmark against other LTC facilities (project-level and nationally)• Improve communication and relationships with referring hospitals that may
results in reduced readmissions• Improve compliance with survey requirements related to quality of care,
infection control, etc.
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Project Goals
Primary Goals—reduce HAIs/CAUTI and improve safety culture• Develop/adapt evidence-based CAUTI elimination and safety practices and resources
for LTCFs• Reduce CAUTIs and HAIs • Improve safety culture
Secondary Goals—support expanded infection prevention efforts for C. diff, UTI, MDROs, etc. by providing education to:
• Improve hygiene practices (hand, environmental)• Promote antibiotic stewardship • Promote catheter stewardship• Reduce re-hospitalizations
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Project Spread420 Active Facilities in Cohort 1, 2 & 3
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Aim to involve all 50 states, D.C. and Puerto Rico
Cohort 1 (63 facilities)
Cohort 2 (152 facilities)
Cohort 3 (203 facilities)
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ACHIEVING PROJECT GOALS
Amanda Wilkins, MPA
Program Manager at HRET
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How will These Goals be Achieved?
Clinical Interventions• Evidence-based infection prevention
practices• Indwelling catheter, UA/culture and
antibiotic stewardship• Strategies to avoid re-hospitalizations,
catheter alternatives
Cultural Interventions • Learning from defects to understand
and prevent adverse events• Senior leadership engagement• Front-line staff empowerment• Teamwork and communication• Regular team meetings
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Educational Sessions
In-person or virtual learning sessions: kickoff, mid-course and final• Slides, expert faculty, interactive activities, handouts, resources
Educational webinar/video series
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Name of series # of Topics
Frequency What Format for Facility Team Lead
Format for Front-line Staff
Onboarding 4 Weekly Project orientation
Webinar Trained by Facility Team Lead
Training Modules 4 Once every two weeks
Infection prevention
Videos Videos, and trained by Facility Team Lead
Safety Culture Survey Results Forum
1 Once Safety culture Webinar N/A
Content ~10 Monthly Clinical and cultural interventions
Webinar Trained by Facility Team Lead
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Education Series Schedule
Onboarding Webinar Series Date Time
1. Building a Culture of Safety Team Thursday, August 6 1:00 – 2:00 p.m. CT
2. CAUTI Definitions Thursday, August 13 1:00 – 2:00 p.m. CT
3. CAUTI Surveillance Thursday, August 20 1:00 – 2:00 p.m. CT
4. Data Collection Training Thursday, August 27 1:00 – 2:00 p.m. CT
Training Module Series Release Date
1. Hand Hygiene Week of Aug 31 N/A
2. Environment & Equipment Week of Sep 14 N/A
3. Isolation Precautions Week of Sep 28 N/A
4. Antibiotic Stewardship Week of Oct 12 N/A
Monthly Webinar Series Date Time
National Content 3rd Thursday of each month, beginning in November
11:15 a.m. – 12:15 p.m. CT
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Support for Education Components
• Train-the-Trainer Guide• Core Team Training Materials
• Webinar Recording• Core Team Presentation Slides
(Chat Summary and Q&A)• Supplemental Materials
• All Staff Training Materials• Video and Facilitator Slides• Discussion Guide/Activity• Event Evaluation Template• Certification of Completion Template
• Additional Resources
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Coaching Calls
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Ashley Hofmann, MSW
Katie Johnson, MHS
Anna Wojcik, MPH
What: State/Region-specific coaching call
When: Monthly, beginning in September
Who: All facility team leads
Facilitated and run by the organizational lead
Faculty coach provides clinical and cultural expertis
HRET advisor provides project management support and technical assistance
Why: Review data and track project progress
Discuss educational webinars and project interventions
Share successes, challenges and best practices with other facilities
Ask Faculty Coach and facility teams to engage in use of project tools, resources
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Resources
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• Your Organizational Lead• LTC Safety Website
username & password: ltcsafety
• Weekly Newsletters• Expert Faculty Coaches• Facility Implementation Guide• Data Support
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MEASURING PROGRESS
AJ Rolle, MPH
Program Manager at HRET
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Purpose of Measurement
Measures are developed to support hard-wiring of resident safety processes with attention to the needs of the LTC environment.
Improving safety and quality of life for residents and their families is our overall aim!
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Required Data Metrics and Schedule
Data Collected Frequency Time to Complete
Background/Cultural Measures -> Drive Change
Registration 1x to enroll 10 minutes
Facility Demographics Baseline 15 minutes
Safety Culture Survey Baseline and follow-up 10 minutes
Process Measures -> Evidence-based practice
Team Communication Guide Quarterly 10 minutes
Skills Questionnaire Baseline, mid-point, final 15 minutes
Outcome Measures –> Understand and celebrate success
Catheter Utilization CAUTI rates Urine culture order rates
Monthly
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Data Collection Systems
Cvent
(web-based survey portal)– Registration– Facility Demographics– Skills Questionnaire– Safety Culture Survey– Event evaluations
Comprehensive Data System
(HRET’s online data portal)– Team Communication– Outcome Measures*
• Residents• Residents with catheters• New CAUTI events• Urine culture orders
*CDC’s National Healthcare Safety Network (NHSN) can also be used for the outcome measures. Facilities must confer rights to HRET (instructions to follow)
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Measurement Support
• Checklist tools to support awareness and adherence to evidence-based recommendations
• NHSN CAUTI definition assessment worksheet
• NHSN CAUTI definition pocket cards
• Data collection tools
• Reports distributed within 4-6 weeks after submission deadlines
• Support for survey and certification regulation compliance with F-tag 315 and F-tag 441
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FACILITY TEAM LEAD ROLE
Louella Hung, MPH
Senior Program Manager at HRET
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How We Will Support You
Your Lead Organization will…• Guide you through the enrollment process • Monitor your progress and assist you with local implementation• Send you short electronic weekly updates about upcoming project milestones,
reminders and tips for success
HRET and Other Members of the National Program Team will…• Provide you with an implementation manual at your kick-off meeting• Have subject matter experts available outside of content calls• Troubleshoot any data and program implementation issues
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Facility Team Expectations
• Promote the project goals • Learn and implement the clinical and cultural improvement tools• Participate in monthly team safety huddles to review outcome, process, and
teamwork and communication data • Attend three face-to-face or virtual learning sessions in your area• Comply with data collection and submission requirements, including the
completion of the AHRQ culture survey, Nursing Home Survey on Patient Safety Culture, at the beginning and end of the program
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Facility Team Lead Expectations
• Time Commitment: 5-7% FTE or 110-135 hours during the 13-14-month program
• Promote project goals
• Lead the facility’s technical & cultural interventions
• Attend all educational sessions: 3 in-person meetings (kick-off, mid-year, final) 2.5 months of monthly onboarding webinars and training modules 10 months of monthly content webinars 10 months of coaching calls
• Train front-line staff in 10-15 minute modules (provided by HRET)
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Facility Team Lead Expectations
Track facility progress and meet data requirements: Submit process and outcome data Safety culture survey (twice: baseline and re-measurement)
Meet regularly with LTC facility team to monitor progress Complete teamwork and communication tool, monthly Hold safety meetings with the team, monthly
Ask for help on behalf of the team Call your organizational lead to discuss team and program challenges, monthly
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TIMELINE & NEXT STEPS
Helen Plass, MA
Program Manager at HRET
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Cohort 4 Timeline for Facilities
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Important Dates for Cohort 4
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Activity Date/Time
Learning Session #1 July 1-24
Registration Due July 24
Onboarding Educational Series 3rd Thursday of each month from 1:00-2:00 p.m. CT, beginning in August
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QUESTIONS ABOUT ENROLLMENT?
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State Organization Organizational Lead Email
Multi-state The Joint Commission Beth Ann Longo [email protected]
Multi-state Leading Age Carol Scott [email protected]
CA Plum Healthcare, for California Association of Health Facilities
Anna Soliven [email protected]
LA eQ Health Solutions – Quality Insights Julie KuekerBeth Hoover
[email protected]@eqhs.org
MN Minnesota Hospital Association Tania DanielsSusan Klammer
[email protected]@mnhospitals.org
NJ New Jersey Hospital Association Patricia Dimino [email protected]
ND Quality Health Associates of North Dakota Michelle Lauckner [email protected]