compass hiin toolkit
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Compass HIIN Reporting Toolkit Version 1.0
1
Compass Hospital Improvement
Innovation Network (HIIN)
Metric and Measurement Toolkit
Version 1.0
Updated November 4, 2016
This collaborative project was developed by: Iowa Healthcare Collaborative (IHC) and the Hospital
Improvement Innovation Network (HIIN)
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Contents Compass HIIN Data Reporting .............................................................................................................. 4
IHC HIIN Data Sources ........................................................................................................................ 4
Statewide Databases (IPOP)............................................................................................................ 4
National Safety Healthcare Network (NHSN) ................................................................................ 5
Self-Reported ...................................................................................................................................... 5
Sampling .............................................................................................................................................. 5
Reporting Deadlines ............................................................................................................................ 6
PfP Compass HIIN Reporting Database ......................................................................................... 7
Login and Registration Screen ......................................................................................................... 8
Open Month Management ................................................................................................................ 8
Metric Selection Screen .................................................................................................................... 9
Data Entry Screen ............................................................................................................................ 10
On-Demand Reports .......................................................................................................................... 11
Run Chart .......................................................................................................................................... 11
Goal Attainment Report ................................................................................................................... 13
CEO Dashboard ............................................................................................................................... 14
Core Focus Areas .................................................................................................................................. 16
Person and Family Engagement (PFE) ........................................................................................ 16
PFE Measures ................................................................................................................................. 16
PFE 1: ................................................................................................................................................ 16
PFE 2: ................................................................................................................................................ 17
PFE 3: ................................................................................................................................................ 18
PFE 4: ................................................................................................................................................ 18
PFE 5: ................................................................................................................................................ 19
Adverse Drug Events (ADE) ............................................................................................................ 21
Clostridium difficile ........................................................................................................................... 30
Catheter Associated Urinary Tract Infection (CAUTI) .............................................................. 36
Central Line Associated Blood Stream Infections (CLABSI) ................................................. 41
Falls and Immobility .......................................................................................................................... 45
Pressure Ulcers .................................................................................................................................. 54
Readmissions and Care Coordination ......................................................................................... 57
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Severe Sepsis and Septic Shock ................................................................................................... 65
Surgical Site Infection (SSI) ............................................................................................................ 70
Ventilator Associated Events (VAE).............................................................................................. 78
Venous Thromboembolism (VTE) .................................................................................................. 83
Additional Focus Areas (Optional) .................................................................................................... 88
Multi-drug Resistant Organism (MDRO) and Antimicrobial Stewardship ........................... 88
Hospital Culture of Safety (Worker Safety) ................................................................................. 92
Undue Exposure to Radiation ......................................................................................................... 96
Obstetrical Adverse Events ........................................................................................................... 100
ED Transfer Communication (MBQIP, for applicable facilities) ........................................... 106
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Compass HIIN Data Reporting During the Hospital Engagement Network (HEN), the Iowa Healthcare Collaborative (IHC) HEN
built a web-based Partnership for Patients (PfP) HEN Reporting Database (the Database) to
track and monitor progress toward the campaign PfP Aims. This PfP Reporting Database
design supported the improvement work of network hospitals and allowed hospitals to monitor
trends in Process and Outcomes measures.
Now in the Hospital Improvement Innovation Network (HIIN), the PfP Compass HIIN Reporting
Database will continue to allow identified HIIN network hospital leadership (e.g. – Quality
Director, Infection Preventionist, etc.) to securely and privately enter hospital performance
metric data and quality improvement (QI) project data. Importantly, the Database serves as a
Quality Measurement and Reporting System (QMRS) for the HIIN program. The Database can
be accessed, through secure login, by hospitals and Compass
The Database allows IAs and hospital HIIN program staff to accomplish a variety of project
management functions. The Database allows IHC, SDAHO and Telligen to assist hospital
project management designees in monitoring, tracking data management, and improvement
activities. HIIN program staff utilize the Database reporting functions to communicate program
performance to hospital leadership and to support Compass HIIN contract program
management and reporting functions.
Hospital staff can access on-demand run charts, goal attainment reports, and dashboards for all
measures after completing monthly data entry requirements. These reports are vital tools that
can be shared during hospital team meetings to track and to drive clinical improvement efforts.
Compass HIIN network hospitals are expected to:
Complete a work plan to begin reporting
Select from a menu of measures to comply with submission of at least one outcome and
one process measure for each focus area that applies to the hospital services
Confer NHSN rights for all applicable measures
Select from menu of optional focus areas (MDRO/Antimicrobial stewardship, Hospital
Worker Safety, and Undue Exposure to Radiation)
IHC HIIN Data Sources
Statewide Databases (IPOP)
Where available, IHC will process monthly data to return point-in-time monthly data points
utilizing available submitted information submitted on or around the 20th of each month. These
data will be grouped utilizing 1) the AHRQ (Agency for Healthcare Research and Quality)
Quality Indicator Grouping methodology, 2) existing relevant codes to identify records with ICD-
10 codes identifying numerators and 3) patient linking capabilities to identify readmissions.
Facilities where statewide databases are not accessible, see Self-Reported below.
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National Safety Healthcare Network (NHSN)
Hospital must confer rights for all applicable measures to the Iowa Healthcare Collaborative. On
or around the 20th of each month, IHC will download updated NHSN information for all HIIN
hospitals. These data are uploaded into the HIIN database for HIIN contacts to use for process
improvement.
Self-Reported
Measures requiring data mining/abstraction may utilize sampling methodologies. See
Improvement Advisors for options. Monthly data are due 45 days after the end of a month.
Access the Compass HIIN Reporting Database through a secure login to input hospital
information. Reports will immediately display updated information.
Sampling
Measurement should speed improvement, not slow it down. Often, organizations get bogged
down in measurement and delay making changes until they have collected all of the data they
believe they require. Remember, measurement is not the goal; improvement is the goal. In
order to move forward to the next step, a team needs just enough data to make a sensible
judgment as to next steps. Instead of measuring the entire process (e.g., all patients waiting in
the clinic during a month; all transfers from the ICU to the floor), measuring a sample (e.g.,
every sixth patient for one week; the next eight patients) is a simple, efficient way to help a team
understand how a system is performing. Sampling saves time and resources while accurately
Claim data submitted to state entity
Point-in-time data pulled
around 20th of each month
Data grouped and mined for
applicable measures
HIIN database refreshed
Run charts -Goal reports -
Dashboard report show
updated information
NHSN information submitted
Point-in-time data pulled around 20th of
each month
HIIN database refreshed
Run charts - Goal reports - Dashboard
report show updated information
Data mining and/or abstraction occurs internally
Data entry into HIIN Data Collection Tool
Run charts - Goal reports -Dashboard report
immediately display updated information
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tracking performance. The recommended sample size is 15-20% of the population you are
sampling. However, when you have a larger sample your data will be more valid and accurate
because it will represent your population appropriately.
Sampling has several primary purposes:
Provide a logical way of making statements about a larger group based on a smaller
group
Allow researchers to make inferences or generalize form the sample to the population if
the selection process has been random and systematic
Sampling Types:
Simple random sampling – The entire population has a chance of being selected. Ex.
Pulling a name out of a hat.
Systematic sampling – After picking the first patient, using every nth patient. Ex. Picking
every 5th patient.
Stratified random sampling – Picking a specific group or stratum from the population and
then randomly pick from that subpopulation. EX. Sex, diagnosis, department.
Cluster sampling – Divide the population into groups and then taking a random sample
for the group of interest. EX. Take all hospitals and divide them into individual hospitals
and then draw randomly from the individual hospital.
NAHQ Q Solutions Essential Resources for Healthcare Quality Professional, Information
Management RobertJ Rosati, PHD pg 41-42
Sampling Resource:
IHI Sampling
Directions for Systematic and Block Sampling
Reporting Deadlines Monthly data are due 45 days after the end of a month:
Self-reported measures must be entered into the data collection database explained in
this document.
Where available, the statewide database/claims data (SID - statewide inpatient
database, SOD - statewide outpatient database) will be utilized for populating select
measures.
o Hospital Quality leads/Primary HIIN contacts are encouraged to work with
inpatient/outpatient data submission personnel in their facilities to make results
available in a timely manner
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NHSN metrics that are conferred to IHC and entered within 45 days after the end of a
month will be downloaded for inclusion into the Database. Monthly reports will be
refreshed during any subsequent month.
Reporting Deadline 2016-2017
OCTOBER 2016 JUNE 2017
All reporting due December 15, 2016 60 Day CEO reminder sent out on January 1, 2017
All reporting due August 15, 2017 60 Day CEO reminder sent out on September 1, 2017
NOVEMBER 2016 JULY 2017
All reporting due January 15, 2017 60 Day CEO reminder sent out on February 1, 2017
All reporting due September 15, 2017 60 Day CEO reminder sent out on October 1, 2017
DECEMBER 2016 AUGUST 2017
All reporting due February 15, 2017 60 Day CEO reminder sent out on March 1, 2017
All reporting due October 15, 2017 60 Day CEO reminder sent out on November 1, 2017
JANUARY 2017 SEPTEMBER 2017
All reporting due March 15, 2017 60 Day CEO reminder sent out on April 1, 2017
All reporting due November 15, 2017 60 Day CEO reminder sent out on January 1, 2018
FEBRUARY 2017 OCTOBER 2017
All reporting due April 15, 2017 60 Day CEO reminder sent out on May 1, 2017
All reporting due December 15, 2018 60 Day CEO reminder sent out on January 1, 2018
MARCH 2017 NOVEMBER 2017
All reporting due May 15, 2017 60 Day CEO reminder sent out on June 1, 2017
All reporting due January 15, 2018 60 Day CEO reminder sent out on February 1, 2018
APRIL 2017 DECEMBER 2017
All reporting due June 15, 2017 60 Day CEO reminder sent out on July 1, 2017
All reporting due February 15, 2018 60 Day CEO reminder sent out on March 1, 201
MAY 2017 JANUARY 2018
All reporting due July 15, 2017 60 Day CEO reminder sent out on August 1, 2017
All reporting due March 15, 2018 60 Day CEO reminder sent out on April 1, 2018
MBQIP Reporting Deadlines
Q1 (January – March) – Due April 15
Q2 (April – June) – Due July 15
Q3 (July – September) – Due October 15
Q4 (October – December – Due January 15
PfP Compass HIIN Reporting Database Follow the narrative below for login and database navigation instructions.
First, click the following link to access the PfP HEN Reporting Database:
http://pfp.ihconline.org/
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Login and Registration Screen
Login using full email address as username and the secure password set up on registration.
Password is cap sensitive. Dual Authentication will be necessary for entry into the database.
This will occur each time the user logs in by the use of a “captcha” phrase.
A forgotten password feature is available if necessary. Enter email address into the field
designated, click on “Forgot Password” and current password will be automatically emailed to
that address.
New users may register by following the New User Registration prompts. All user registrations
must be approved by the system administration (Compass HIIN staff) prior to the user being
granted access to the database. A confirmation email will alert user when access is confirmed.
Open Month Management
The Open Month Management screen allows the user:
Access to select metrics for open months
Access for entry of data in open months
Informational messaging on monthly data entry status
Access to on-demand reports
Access to the Compass HIIN Reporting Toolkit
Link to contact IHC Helpdesk to request technical assistance
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See screenshot below:
Metric Selection Screen
Hospitals are required to report on at least one process and at least one outcome measure for
each of the focus areas (*with the exception of ADE and falls process measures) that match
their service delivery (e.g. – hospitals that do not care for ventilator patients are excluded from
the requirement to submit data on Ventilator Associated Events). To select the metrics, each
hospital will determine their options. Mark the checkbox to the left of the desired metrics.
Choices will be continued in any subsequent month but changes to reporting options are
available at any time.
*Hospitals must report on all ADE and Falls process measures.
Metric Selection - Navigation buttons at the top and bottom of the page include:
Save and Home – saves any changes and takes user back to the Welcome page
Save and Enter Data – saves any changes and takes user to the data entry page
Home – does not save changes and takes user to the Welcome page
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Data Entry Screen
General rules applying to all metrics:
All facilities must select at least one process and at least one outcome measure per
focus area, with the exception of ADE and falls process measures
Interventions may be entered for each month in which they occur (NOTE: this
information will appear on reports)
Fields are numeric only. Do not use decimals or characters
Please note that on PFE only a Yes/No choice is available
Edits will apply only upon selection of Complete Month
Discharges are reported in the month of the discharge date
Data Entry - Navigation buttons at the top and bottom of the page include:
Save Data – saves any changes and user remains on data entry page
Save Data/Return Home – saves any changes and takes user to the Welcome page
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Run Edits – applies system edits against all fields and returns data entry problems
Complete Month – saves all changes, communicates that data entry is done for the
month, runs edits and takes user to the Welcome page if no data issues are found. If
edits are highlighted, they must be corrected in order to save data entered
**Remember to save after each update. If the information is not saved, the user will be
prompted to save before leaving the page through a popup alert.
On-Demand Reports
Run Chart
Run or control charts are graphic displays of data points over time. Run charts are control charts
without the control limits.
Run charts available within the Compass HIIN Reporting Database are customizable allowing
users to add upper and lower control limits, add a trend line, and/or add data point labels to the
run chart. Users are able to run the report format as a pdf or export data into excel format to
allow for further customization and workability.
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Control limit: Control limits of your run chart represent your process variation and help
indicate when your process is out of control. Control limits are used to detect signals in
data that indicate that a process is not in control and, therefore, not operating
predictably. The upper and lower control limits are based on the variation in your facility
data.
Trend line: A line on a graph showing the general direction that a group of points seem
to be heading.
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Select “View Run Charts” on the Welcome page to generate hospital-specific report.
On-demand reports display monthly data points all reported months
Comparative results are displayed within run charts
For concerns or questions regarding data please contact your Improvement Advisor
Goal Attainment Report
Data are populated into the Goal reports from multiple sources (Statewide Databases (where
available), NHSN, or Self-reported). Hospital-level results are provided within this report to allow
users to determine facility performance.
Goal reports are customizable by measure and performance period and can be populated on-
demand by hospital quality staff from within the PfP Compass HIIN Reporting Database.
Goals reports contain baseline and performance data (including numerator and denominator
data) pertinent to the performance time frame specified by the user. Baseline periods included
within the goal reports are based on a 12-month time period. Performance period will be
populated as a 3-month time frame based on the performance end data selected by the user.
Within the Goal Report improvement percentages (i.e. percent changed from baseline period)
are calculated per measure.
*Please note that there may be blank cells on the Goal Reports. Blank cells indicate no data
were present in the timeframes designated for baseline and/or performance. If no data are
populated in the baseline and/or performance column(s), then the improvement column will also
be blank. Please contact your Improvement Advisor if cells are blank. They will assist with
identifying the reason for blank cells.
Goal Reports can be found on the reporting page along with other HIIN reports.
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CEO Dashboard
The CEO dashboard provides a “stoplight” view of current hospital progress toward HIIN goals.
Data are populated into CEO dashboard reports from multiple sources (Statewide Databases
(where available), NHSN, or Self-reported). In addition to hospital-level results, comparative
data are provided to allow users to determine facility performance compared to peer group,
Statewide averages and Compass HIIN network averages. Peer groups are divided by hospital
Medicare class and are combined into two groups: 1) Critical Access + Rural and 2) Rural
Referral + Urban.
Within the dashboard improvement percentages (i.e. percent changed from baseline period) are
calculated per measure. A positive number is an improvement, while a negative number
signifies a decline. Please keep in mind that the performance period is a moving target and
actual performance may change from month to month. CEO Dashboards are customizable by
measure and performance period and can be populated on-demand by hospital quality staff
from within the PfP Compass HIIN Reporting Database.
Breakdown of levels of achievement within the CEO Dashboard are as follows:
Red – <0%. No improvement, or performing below 0% improvement, or worsening for all
Healthcare Acquired Conditions (HACs) and Readmissions.
Yellow – 0 - 19% for all HACs. 0 - 11% for Readmissions. This means hospitals are maintaining
current level of improvement or showing progress toward goals but has not yet reached the
program goals. Hospitals that maintained a 0% improvement will be included in this category.
Green – 20% or greater for all HACs. 12% or greater for Readmissions. Hospital has met or is
exceeding the program goal.
*Please note that there may be blank cells on the CEO Dashboard. Blank cells indicate no data
were present in the timeframes designated for baseline and/or performance. If no data are
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populated in the baseline and/or performance column(s), then the improvement column will also
be blank. Please contact your Improvement Advisor if cells are blank. They will assist with
identifying the reason for blank cells.
CEO dashboards can be found on the reporting page along with other HIIN reports.
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Core Focus Areas Person and Family Engagement (PFE)
Previous HEN campaigns have built a solid foundation for Person and Family
Engagement (PFE), recognizing that partnering with patients and families is a critical
factor in achieving improvements in the quality and safety of care.
In HIIN, CMS continues to focus on PFE as a necessary component of improved quality
and safety. Five PFE metrics are included in monthly data collection. Hospitals will re-
evaluate their PFE status and make changes as necessary on a monthly basis.
Recommended PFE team members
Quality staff
Providers
Pharmacist
Department Managers/Directors
Frontline staff
Patient and Families
Health Coach
Social Worker/Case Manager
Doctor Office/Clinic Staff
Nursing Home
Home Care
PFE Measures
PFE 1:
Prior to scheduled admission, hospital staff provides and discusses a planning checklist
that is similar to CMS Discharge Planning Checklist with every patient, allowing time for
questions and comments from patient and family.
Tips and Tricks
Implementation of modified discharge checklist for use for all admissions
Utilize CMS Discharge Planning Checklist as a guide
Educate and ensure that information related to the importance of Patient and Family education is provided at new employee orientation and ongoing education throughout the year (Ex. Monthly staff meetings and competency/skill fairs)
PFE 1 Resources
AHRQ Strategy 4: Care Transitions from Hospital to Home - IDEAL Discharge Planning
Patient and Family as full partners in the discharge planning process. 5 key areas to prevent problems at home. Documents on Discharge Planning
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CMS Discharge Planning Checklist Sample of discharge planning with resources to consider
AHRQ Communicating to Improve Quality Documents to encourage patient participation in care
NAQC Fostering Successful Patient and Family Engagement: Nursing’s Critical Role What is patient engagement, why is patient engagement a nursing priority? Model and roadmap for nurse contribution to patient engagement
PFE 2:
Hospital conducts shift change huddles and does bedside reporting with patients and
family members in all feasible cases.
Tips and Tricks
Implement and maintain consistence of daily huddles
Implement and utilize huddle boards
Implement and review bedside report checklist
Utilize scripting for bedside reporting
Daily huddles should include: fall risk, Braden score, VTE prophylaxis, patients on warfarin, opioids or high risk medications, and expected discharge dates
Provide patient and family with information on bedside shift report to encourage participation
PFE 2 Resources AHRQ Strategy 3: Nurse Bedside Shift Report Bedside checklist, training and education
Bedside Shift Report Tools & Resources from Vanderbilt Medical Center Nursing Department Resources for bedside shift report and hourly rounding
AHRQ Nurse Bedside Shift Report Implementation Handbook Rationale, implantation and case studies for bedside shift report
AHRQ Nurse Bedside Shift Report Brochure Brochure for patient and family education
AHRQ Bedside Shift Report Checklist Checklist including SBAR
AHRQ Training PowerPoint
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Nurse bedside shift report training. Education on patient and family engagement, components of bedside shift report, HIPAA information and practice exercises
AHRQ Training PowerPoint - PDF Format
PFE 3:
Hospital has a dedicated person or functional area that is proactively responsible for
patient and family engagement and systematically evaluates patient and family
engagement activities.
Tips and Tricks
Create a staff liaison to develop the infrastructure for the patient and family advisors
Provide education and prepare hospital leadership
Create a patient and family advisory council or start with a short term project that involves patient and family advisors
PFE 3 Resources
AHRQ Working with Patient and Families as Advisors - Implementation Handbook
Resources include identifying a staff liaison, opportunities for PFAC, recruiting, selecting
and training
Patient and Family Advisor - Orientation Manual
Responsibilities, expectations, tips for being an engaged advisor
AHRQ Guide to Patient and Family Engagement in Hospital Quality and Safety
4 primary strategies for promoting patient/family engagement in hospital safety and
quality of care
Patient Engagement Who, What, Why
PFE 4:
Hospital has an active Patient and Family Engagement Committee or at least one
former patient that serves on a patient safety or quality improvement committee or
team.
Tips and Tricks
Utilize the below resources to invite and train patient and family advisors
PFE 4 Resources
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Pt and Family Advisor Tools:
AHRQ Patient and Family Advisor Application Form
Become a Patient and Family Advisor - Brochure
Am I Ready to Become an Advisor - Checklist
Confidentiality Statement for Advisors
Patient and Family Participation Interests
Do You Have Ideas to Help Improve our Hospital? - Postcard
Readiness to Partner with Patient and Family Advisors
Sample Letter of Invitation for Advisory Council Applicants
Sharing My Story: A Planning Worksheet
Working with Patient and Family Advisors
Working with Patient and Family Advisors on Short-Term Projects
Become a Patient and Family Advisor: Information Session
Working with Patient and Family Advisors: Introduction and Overview
Policy and Protocol Tools:
PFCC Go Shadow
Patient and Family Centered Care Methodology and Practice. Build care teams,
develop high-performance care teams, drive change and innovation
AHA Strategies for Leadership: Patient and Family Centered Care
Videos, resource guide and hospital self-assessment tool for Patient and family
centered care
Institute for Patient and Family Centered Care - Free resources
Strategies for Leadership, tools to foster the collaboration with patient and family
advisors and tools to assist in designing supportive health care environments
Advancing the Practice of Patient- and Family-Centered Care in Hospitals
Education on patient and family centered care, rationale, role of the leaders, selecting
preparing and supporting patient and family advisors and checklist for attitudes about
partnering with patients and families
Partnering with Patients and Families to Enhance Safety and Quality: A Mini Toolkit
Patient and family advisors vision, applications
PFE 5:
Hospital has at least one or more patients who serve on a governing or leadership
board and serves as a patient representative.
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Tips and Tricks
Create and implement the PFE Roadmap
Determine what the current hospital culture is regarding patient and family engagement
PFE 5 Resources
The Power of Having the Board on Board
6 crucial activities for boards
H2Pi Effecting Safety Across the Board Through Patient and Family Partnership
Councils for Quality and Safety (PEPCQS)
Tools, assessment of your organization, roadmap to success, strategic planning
Engaging Health Care Users: A Framework for Health Individuals and Communities
Guide
Strategies at the community, organization, health care team and individual levels
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Adverse Drug Events (ADE) An adverse drug event (ADE) is an injury resulting from the use of a drug. ADEs in hospitals can be caused by medication errors, such as accidental overdoses or providing a drug to the wrong patient, or by adverse drug reactions, such as allergic reactions or excessive bleeding after treatment with the intended dose of a drug that prevents dangerous blood clots. These measures look at the number of adverse drug events in the acute care, skilled nursing, swing bed, and observation units. In addition, these measures look at the number of lab measurements, blood glucose measurements, and electronically entered med orders in the inpatient setting. New pediatric measures have been added. See below for more detailed information about each measure. These measures help to determine how many and how often patients are harmed by ADEs.
Measures
Outcome Measures: Adverse Drug Event Rate
Numerator: Number of Acute Care, Skilled Nursing Facility, Swing Bed and Observation adverse drug events
Denominator: Number of Acute Care, Skilled Nursing Facility, Swing Bed and Observation patient days
Data Sources
Self-Reported
Recommended team members
Quality staff
Providers
Pharmacist
Department Managers/Directors
Frontline staff
Patient and Families
Clinical IT
Tips and Tricks
Assemble an interdisciplinary team and develop an AIM statement that reflects organizational ADE goals
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Educate and ensure that ADE education is provided at new employee orientation
and ongoing education throughout the year (Ex. Monthly staff meetings and
competency/skill fairs)
Implement use of NCC MERP Scale Categories D-I for categorization of adverse
drug events
Utilize the NCC MERP algorithm
“0” denominator not allowed
Engage leadership on the importance of creating a just culture that allows front-line to feel empowered to fill out incidents reports when medication error occur
Provide Nursing education on ADE reporting and the importance of reporting near misses as well as reporting situations that cause harm
Resources
HRET Top Ten Checklist for ADE Top ten evidence based interventions for ADE
The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Medication Errors Definition, taxonomy and index for categorizing medication errors
NCC MERP Index for Categorizing Medication Errors Pie chart demonstrating medication errors categories A-I
NCC MERP Index for Categorizing Medication Error Algorithm Algorithm to categorize medication errors
University of Southern California School of Pharmacy Medication Therapy Intervention & Safety Documentation Program User Manual (v 7.0), pages 8-9. Adverse Drug Reaction (ADR) definition
Agency for Healthcare Research and Quality (AHRQ) H-CUPs Medication-Related Adverse Outcomes in U.S. Hospitals and EDs
Office of Disease Prevention and Health Promotion National Action Plan for Adverse Drug Event (ADE) Prevention H CUP Statistical Brief #109 Provides characteristics and medications most commonly involved in ADEs
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Adverse Drug Events Originating During Hospital Stay (AHRQ) Numerator: Number of Acute Care adverse drug events that cause harm
Denominator: Number of Acute Care, Skilled Nursing Facility and Swing Bed discharges
Data Sources
IPOP/Claims Data (where available)
Self-Reported
Recommended team members
Quality staff
Providers
Pharmacist
Department Managers/Directors
Frontline staff
Patient and Families
Clinical IT
HIM
Tips and Tricks
Assemble an interdisciplinary team and develop an aim statement that reflects your organization's ADE goals
Educate and ensure that ADE education is provided at new employee orientation
and ongoing education throughout the year (Ex. Monthly staff meetings and
competency/skill fairs)
Ensure that your Pharmacist is communicating with coders to ensure proper
coding (applicable for claims data)
“0” denominator not allowed
Provide Nursing education on ADE reporting and the importance of reporting near misses as well as reporting situations that cause harm
Resources
HRET Top Ten Checklist for ADE Top ten evidence based interventions for ADE University of Southern California School of Pharmacy Medication Therapy Intervention & Safety Documentation Program User Manual (v 7.0), pages 8-9. Adverse Drug Reaction (ADR) definition Agency for Healthcare Research and Quality (AHRQ) H-CUPs Medication-Related Adverse Outcomes in U.S. Hospitals and EDs
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Office of Disease Prevention and Health Promotion National Action Plan for Adverse Drug Event (ADE) Prevention Process Measures: *ADE Process measures for Blood Glucose, INR and Opioids are surrogate measures for measuring harm. These measures may include an Adverse Drug Event (ADE) or Potential Adverse Drug Event (pADE). It is critical that the HIIN team evaluate all data and assess level of harm according to the NCC-MERP scale.
Blood Glucose Less Than 50 Numerator: Number of blood glucose measurements (per lab reports, POCT, EMR, Charge Data, etc.) for Acute Care, Skilled Nursing Facility, Swing Bed and Observation patients where blood glucose <50
Denominator: Number of blood glucose measurements (per lab reports/POCT, EMR, Charge Data, etc.) for Acute Care, Skilled Nursing Care, Swing Bed and Observation patients
Data Sources
Self-Reported
Recommended team members
Quality staff
Providers
Pharmacist
Department Managers/Directors
Frontline staff
Patient and Families
Clinical IT
Physical/Occupational/Speech Therapy staff
Lab
Dietitian
Tips and Tricks
“0” denominator not allowed
Exclude ED patients
Include Blood Glucose measurements less than 50 that occur only after patient is admitted to inpatient unit, exclude ER Blood Glucose Measurements less than 50
Include discussion of patients with hypoglycemia risk at your daily huddles and
individualize their interventions for safety
Include all lab results and blood glucometer readings
Implement the Basal Bolus Insulin Protocol
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Anticipate hypoglycemic events in patients with history of hypoglycemia
Educating diabetic patients and family members about symptom recognition of hypoglycemia
Develop a process to ensure that alternate methods are ordered for diabetes control if patient is unable to take their oral diabetes medication
Resources
Healthcare Communities
Basal Bolus Insulin Therapy – Inpatient Management
INRs Greater Than 5 Numerator: Number of lab measurements for Acute Care, Skilled Nursing Facility, Swing Bed and Observation patients on Warfarin where documented INR >5
Denominator: Number of INR lab measurements for Acute Care, Skilled Nursing Facility, Swing Bed and Observation patients on Warfarin
Data Sources
Self-Reported
Recommended team members
Quality staff
Providers
Pharmacist
Department Managers/Directors
Frontline staff
Patient and Families
Clinical IT
Nursing Home
Home Care
Respiratory/Therapy staff
Physical/Occupational/Speech Therapy staff
Lab
Doctor office/Clinic staff
Tips and Tricks
“0” denominator not allowed
Exclude ED patients Include discussion of patients with fall risk at your daily huddles and individualize
their interventions for safety
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Support Pharmacy led warfarin management of inpatients
Small numbers and volumes can be hand collected
Ensure daily concurrent review of patients on warfarin by pharmacy
Weekly or monthly retrospective review of labs for patients on warfarin
Resources
Institute for Safe Medication Practices (ISMP) Improving Medication Safety with Anticoagulant
Stat Naloxone Administration Numerator: Number of episodes when a reversal agent (e.g. naloxone) is administered to Acute Care, Skilled Nursing Facility, Swing Bed and Observation patients prescribed opioids
Denominator: Number of Acute Care, Skilled Nursing Facility, Swing Bed and Observation patients prescribed opioids
Data Sources
Self-Reported
Recommended team members
Quality staff
Providers
Pharmacist
Department Managers/Directors
Frontline staff
Patient and Families
Health Coach
Social Worker/Case Manager
Clinical IT
Nursing Home
Home Care
Respiratory/Therapy staff
Physical/Occupational/Speech Therapy staff
Doctor office/Clinic staff
Tips and Tricks
Exclude ED patients
Assess patient for opioid naïve or tolerance prior to administration of narcotics
Implement visual analog pain scale and conduct pain level assessment prior to initial dose and prior to subsequent doses of narcotics
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Develop a care plan step down treatment plan for decreasing and discontinuing narcotics
Resources
American Society for Pain Management American Society for Pain Management Nursing Guidelines on Monitoring for Opioid-Induced Sedation and Respiratory Depression
Opioid Therapy Treatment Plan Numerator: Number of patients discharged from a hospital on an opioid with patient-specific goals of therapy at discharge
Denominator: Number of patients discharged on opioids
Data Sources
Self-Reported
Recommended team members
Quality staff
Providers
Pharmacist
Department Managers/Directors
Frontline staff
Patient and Families
Health Coach
Social Worker/Case Manager
Clinical IT
Nursing Home
Home Care
Physical/Occupational/Speech Therapy staff
Doctor office/Clinic staff
Tips and Tricks
Exclude ED patients
Administer 1st dose of opioid prior to discharge
Assess patient for opioid naïve or tolerance prior to administration of opioids
Implement visual analog pain scale and conduct pain level assessment prior to initial dose and prior to subsequent doses of opioids
Develop a care plan step down treatment plan for decreasing and discontinuing opioids
Request that IT builds the treatment plan into EHR
Involvement of pharmacist in the treatment plan is favorable
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Resources
CDC Guideline for Prescribing Opioids for Chronic Pain
The guideline addresses: when to initiate or continue opioids for chronic pain, opioid selection, dosage, duration, follow-up, and discontinuation and assessing risk and addressing harms of opioid use
Use of Opioids for the Treatment of Chronic Pain
The American Academy of Pain Medicine offers statements on the use of opioids for the treatment of chronic pain
Utah Clinical Guidelines on Prescribing Opioids for treatment of Pain
Opioid treatment recommendations for acute and chronic pain. How to establish treatment goals and a written treatment plan. Initiating, monitoring and discontinuing opioid treatment. Documentation for EHRs
Utah Treatment Plan Using Prescription Opioids
Patient and prescriber treatment plan
Opioids911-Safety
Examples of treatment plans and pain management agreements
Prevalence of Naloxone Usage in Community Setting Prior to Admission Numerator: Number of patients who received naloxone in community setting prior to admission (Include ambulance, in-home, and law enforcement use of Naloxone)
Denominator: Number of Acute Care admissions
Data Sources
Self-Reported
Recommended team members
Quality staff
Providers
Pharmacist
Department Managers/Directors
Frontline staff
Patient and Families
Health Coach
Social Worker/Case Manager
Clinical IT
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HIM
Nursing Home
Physical/Occupational/Speech Therapy staff
Doctor office/Clinic staff
Local EMS
Local Law Enforcement
Tips and Tricks
Request that IT builds the treatment plan into EHR
Collaborate with your local EMS and Law Enforcement
Provide education of naloxone usage for patients and families
Resources
Substance Abuse and Mental Health Services Administration - Opioid Overdose Toolkit
Includes facts for community members, prescribers and safety advice for patients and family members
CDC Opioid Overdose Prevention Programs Providing Naloxone to Laypersons – United State, 2014
Provides information on organizations that provide naloxone kits to laypersons
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Clostridium difficile Clostridium difficile (C.diff) is a bacterium that causes infections within the digestive system. Measures focus on hospital-acquired C.diff and hand hygiene compliance, looking at hand washing technique. See below for more detailed information about each measure. The current NHSN Manual – Patient Safety Component is utilized for defining and reporting on these measures. To access the manual, follow this link: http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf. These measures will help to determine how many and how often patients are harmed by C.diff.
Measures
Outcome Measures:
Healthcare facility-onset Clostridium difficile Infection Rate
Numerator: Number of healthcare facility-onset Clostridium difficile infections
Denominator: Number of acute care inpatient days
Data Sources
NHSN
Recommended team members
Quality staff
Infection Preventionist
Providers
Pharmacist
Department Managers/Directors
Frontline staff
Patient and Families
Health Coach
Social Worker/Case Manager
Nursing Home
Home Care
Hospice
Lab
Doctor office/Clinic staff
Dietitian
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Tips and Tricks
Assemble an interdisciplinary team and develop an aim statement that reflects your organization's C diff goals
Educate and ensure that C diff prevention and handwashing education is
provided at new employee orientation and ongoing education throughout the year
(Ex. Monthly staff meetings and competency/skill fairs)
Participate in the HAI Community of Practice events
Confer NHSN rights to IHC
Develop and implement an Antimicrobial Stewardship Program
Ensure that all doctors, nurses, and other health care providers clean their hands with soap and water or an alcohol-based hand rub before and after caring for patients
Placement of Alcohol-based Hand Hygiene Dispensers to Increase Visitor Use
Select antimicrobials associated with a lower risk of CDI when possible and avoid antimicrobial exposure if patients do not have a condition for which antimicrobials are indicated
Ensure a physician leader dedicates a portion of their time to the design, implementation and function of an antimicrobial stewardship program and is accountable for the program’s outcomes
Provide Clostridium diff infection information for patients
Develop and implement appropriate protocols for sporicidal chemical sterilization of equipment and the environment
Ensure that personnel responsible for environmental cleaning and disinfection have been appropriately trained and are using the correct personal protective equipment
Ensure that Pharmacists conduct a daily review of targeted antimicrobials for appropriateness and contact prescribers with recommendations for alternative therapy
Resources
HRET Top Ten Checklist for CDI Checklist to review current or initiate new interventions for CDI prevention Clostridium difficile (CDI) Infections Toolkit Healthcare-association infection elimination PowerPoint from the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention CDC MDRO and CDI Module NHSN Multi drug resistant organism & clostridium difficile infection Module FAQs about Clostridium difficile (CDC) Fact sheet for patients to have as a resource when they are discharged
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Clostridium difficile Prevalence
Numerator: Number of Clostridium difficile Lab ID events
Denominator: Number of acute care inpatient admissions
Data Sources
NHSN
Recommended team members
Quality staff
Infection Preventionist
Providers
Pharmacist
Department Managers/Directors
Frontline staff
Patient and Families
Health Coach
Social Worker/Case Manager
Nursing Home
Home Care
Hospice
Lab
Doctor office/Clinic staff
Dietitian
Tips and Tricks
Assemble an interdisciplinary team and develop an aim statement that reflects your organization's ADE goals
Assemble an interdisciplinary team and develop an aim statement that reflects your organization's C diff goals
Educate and ensure that C diff education is provided at new employee
orientation and ongoing education throughout the year (Ex. Monthly staff
meetings and competency/skill fairs)
Participate in the HAI Community of Practice
Ensure your rights are conferred in NHSN to IHC
Antimicrobial Stewardship Programs in Health Care Systems
Ensure that all doctors, nurses, and other health care providers clean their hands with soap and water or an alcohol-based hand rub before and after caring for patients
Placement of Alcohol-based Hand Hygiene Dispensers to Increase Visitor Use
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Select antimicrobials associated with a lower risk of CDI when possible and avoid antimicrobial exposure if patients do not have a condition for which antimicrobials are indicated
Ensure a physician leader dedicates a portion of their time to the design, implementation and function of an antimicrobial stewardship program and is accountable for the program’s outcomes
Provide Clostridium diff infection information for patients
Develop and implement appropriate protocols for sporicidal chemical sterilization of equipment and the environment
Ensure that personnel responsible for environmental cleaning and disinfection have been appropriately trained and are using the correct personal protective equipment
Ensure that Pharmacists conduct a daily review of targeted antimicrobials for appropriateness and contact prescribers with recommendations for alternative therapy
Maintain same number of sample audits each month to truly capture improvement and consistent trending
Resources
HRET Top Ten Checklist for CDI Checklist to review current or initiate new interventions for CDI prevention Clostridium difficile (CDI) Infections Toolkit Healthcare-association infection elimination PowerPoint from the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention CDC MDRO and CDI Module NHSN Multi drug resistant organism & clostridium difficile infection Module FAQs about Clostridium difficile (CDC) Fact sheet for patients to have as a resource when they are discharged
Clostridium difficile SIRs (Standardized Infection Ratio) will be obtained from NHSN information conferred to IHC and included in the analysis of statewide and national results for each eligible facility and all reported units
Process Measures:
Hand Hygiene Compliance Numerator: Number of observations where appropriate hand-washing technique was applied
Denominator: Number of observations
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Data Sources
Self-Reported
Recommended team members
Quality staff
Infection Preventionist
Providers
Pharmacist
Department Managers/Directors
Frontline staff
Patient and Families
Health Coach
Social Worker/Case Manager
Tips and Tricks
Educate and ensure that handwashing education is provided at new employee
orientation and ongoing education throughout the year (Ex. Monthly staff
meetings and competency/skill fairs)
Provide demonstration and live validation to ensure method of handwashing is effective
Utilize a standard form that everyone uses for observations, include all staff that have patient interaction
Resources
CDC Hand Hygiene in Healthcare Settings Hand hygiene basics, training, guidelines and measurement Hand Hygiene Observation Record This form can be used when performing hand hygiene observations
Institute for Healthcare Improvement How-to Guide: Improving Hand Hygiene (this is a free resource, sign into IHI to download) interventions for improved handwashing, measurement tools World Health Organization (WHO) Clean Care is Safer Care – Hand Hygiene Tools and Resources WHO Guidelines on Hand Hygiene in Health Care Your 5 Moments for Hand Hygiene – Poster
Contact Precaution Compliance
Numerator: Number of contact precautions performed consistent with guidelines
Denominator: Number of observations
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Data Sources
Self-Reported
Recommended team members
Quality staff
Infection Preventionist
Providers
Pharmacist
Department Managers/Directors
Frontline staff
Patient and Families
Respiratory/Therapy staff
Physical/Occupational/Speech Therapy staff
Lab
Tips and Tricks Educate and ensure that Contact Precaution education is provided at new
employee orientation and ongoing education throughout the year (Ex. Monthly
staff meetings and competency/skill fairs)
Provide demonstration and live validation to ensure method of contact isolation is effective
Utilize a standard form that everyone uses for observations
Ensure availability of gloves, gowns, masks and other protective items
Resources
CDC Basic Infection Control and Prevention Plan for Outpatient Oncology Settings
Please see “B” Contact Precautions, includes conditions and disease to consider when using contact precautions, types of protection and patient education
CDC Precautions to Prevent Spread of MRSA Information on standard and contact precautions
Hand Hygiene/Contact Precautions Monitoring Tool
This form can be used when performing contact precautions observations
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Catheter Associated Urinary Tract Infection (CAUTI) A Catheter-associated Urinary Tract Infection (CAUTI) is a serious infection that occurs when bacteria enter the body through a urinary catheter.
These measures look at catheter utilization in inpatient settings and within the emergency department. The Outcome measure focuses on the number of hospital-acquired urinary tract infections that occur. See below for more detailed information about each measure. The current NHSN Manual – Patient Safety Component is utilized for defining and reporting on these measures. To access the manual, follow this link: http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf. These measures help to determine how many patients are harmed by CAUTIs.
Measures Outcome Measures: Catheter-Associated Urinary Tract Infection Rate
Numerator: Number of hospital-acquired urinary tract infections
Denominator: Number of Acute Care urinary catheter days
Data Sources
NHSN
Recommended team members
Quality staff
Infection Preventionist
Providers
Department Managers/Directors
Frontline staff
Patient and Families
Tips and Tricks
Assemble an interdisciplinary team and develop an aim statement that reflects your organization's CAUTI goals
Educate and ensure that CAUTI education is provided at new employee orientation
and ongoing education throughout the year (Ex. Monthly staff meetings and
competency/skill fairs)
Participate in the HAI community of practice
Include discussion of patients with foley catheters in place at your daily huddles and the possibility to remove the foley catheter
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Confer rights to IHC in NHSN
Request that IT build the acceptable indications for inserting an indwelling catheter into your EHR. Ensure this is on your provider’s screen so they can choose an indication
Implement a system for documenting the following in the patient record: physician order for catheter placement, indications for catheter insertion, date and time of catheter insertion, name of individual who inserted catheter, nursing documentation of placement, daily presence of a catheter and maintenance care tasks, and date and time of catheter removal
Educate patients and families about CAUTIs are and how they can be prevented
Assemble a team to address cultural barriers to CAUTI prevention using the comprehensive unit-based safety program (CUSP)
Resources
HRET Top Ten Checklist for CAUTI Top 10 evidence based interventions
CDC Device-associated Module – CAUTI Urinary Tract Infection (Catheter-Associated Urinary Tract Infection [CAUTI] and Non-Catheter-Associated Urinary Tract Infection [UTI]) and Other Urinary System Infection [USI] Events, Criteria and SIRs
CDC HICPAC CAUTI Guidelines, Strategies for prevention of CAUTI, CAUTI Surveillance
Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals Highlights practical recommendations in a concise format to assist acute care hospitals in implementing catheter-associated urinary tract infection prevention efforts and provides recommendations for surveillance
NHSN Urinary Tract Infection Form This form expires 12/31/2017 *CAUTI SIR (Standardized Infection Ratios) will be obtained from NHSN information
conferred to IHC and included in the analysis of Compass HIIN network and national
results for each eligible facility and reported for two cohorts – one for ICUs and another
for ICUs with Other Reporting Units.
Process Measures:
Unnecessary Urinary Catheters
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Numerator: Number of Acute Care, Skilled Nursing Facility and Swing Bed inpatients with new indwelling urinary catheters inserted without appropriate indication documented
Denominator: Number of Acute Care, Skilled Nursing Facility and Swing Bed inpatients with new indwelling urinary catheter insertions
Data Sources
Self-reported
Recommended team members
Quality staff
Infection Preventionist
Providers
Department Managers/Directors
Frontline staff
Patient and Families
Clinical IT
Tips and Tricks
This measure excludes straight catheters and quick catheters
Educate and ensure that Urinary Catheter insertion criteria education is provided
at new employee orientation and ongoing education throughout the year (Ex.
Monthly staff meetings and competency/skill fairs)
Criteria should include at a minimum: o Perioperative use for selected surgical procedures o Urine output monitoring in critically ill patients o Management of acute urinary retention and urinary obstruction o Assistance in pressure ulcer healing for incontinent patients o As an exception, at patient request to improve comfort (SHEA-IDSA) or for
comfort during end-of-life care (CDC)
Hospitals may add to or modify these criteria for local needs; criteria may be defined in policies or procedures
Ensure access to a bladder scanner. The bladder scanner should be kept in the same location when it is not in use to ensure prompt availability
Request that IT build the acceptable indications for inserting an indwelling catheter into your EHR. Ensure this is on your provider’s screen so they can choose an indication at time of ordering urinary catheter
Utilize a straight catheter when indicated instead of an indwelling catheter
Resources
Institute for Healthcare Improvement
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IHI How-to Guide: Prevent Catheter-Associated Urinary Tract Infections, page 24 (Login
required with free access to information)
CDC Toolkit for Reducing Catheter-Associated Urinary Tract Infections in Hospital Units
Guidelines for the use of a bladder scanner
Urinary Catheter Utilization Ratio
Numerator: Number of Acute Care, Skilled Nursing Facility and Swing Bed inpatient days with urinary catheter in place
Denominator: Number of Acute Care, Skilled Nursing Facility and Swing Bed inpatient days
Data Sources
NHSN
Recommended team members
Quality staff
Infection Preventionist
Providers
Department Managers/Directors
Frontline staff
Patient and Families
Clinical IT
Tips and Tricks
Confer rights to IHC in NHSN
Provide Physician and Nurse education on Catheter Utilization
Include discussion of patients with foley catheters in place at your daily huddles and get them out if possible
Request IT put a counter in the EHR for catheter days
Pilot and spread a nurse-driven removal protocol using the electronic health record system
Every shift, document the ongoing need for the catheter based on a CDC-approved indication
Resources
Algorithm for Removal of Foley Catheter
Algorithm from Mercy Medical Center in Des Moines Iowa
CAUTI Prevention Policy
Urinary catheterization and CAUTI prevention policy document
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Emergency Department Catheter Utilization Numerator: Number of Emergency Department urinary catheter placements in the Emergency Department Denominator: Number of Emergency Department visits
Data Sources
IPOP/Claims Data (where available)
Self-Reported
Recommended team members
Quality staff
Infection Preventionist
Providers
Department Managers/Directors
Frontline staff
Patient and Families
Clinical IT
HIM
Tips and Tricks
Educate ED staff on indications for inserting Urinary Catheters
Utilize bladder scanners
Remove unnecessary catheters before transferring to the inpatient room
Be aware of charging and coding for Urinary Catheters placed in ED
AMA CPT codes that will be utilized to identify catheters inserted in the Emergency Department: 51702, 51703
Have conversations with HIM to ask how they are coding for this measure
Resources Nurse-Initiated Removal of Unnecessary Urinary Catheters in the Non-Intensive Care Units AHRQ funded toolkit that includes appropriate use of urinary catheters and how to promote a urinary catheter removal program
Nurse Driven CAUTI Protocol Nursing urinary catheter removal protocol includes steps of care leading to catheter removal
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Central Line Associated Blood Stream Infections (CLABSI) A central line associated bloodstream infection (CLABSI) is a serious infection that occurs when bacteria enters the bloodstream through a central line.
These measures look at central line compliance and utilization. See below for more detailed information about each measure. The current NHSN Manual – Patient Safety Component is utilized for defining and reporting on these measures. To access the manual, follow this link: http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf. These measures help to determine how many patients are harmed by CLABSIs.
Measures Outcome Measures: Central Line-Associated Bloodstream Infection Rate
Numerator: Number of hospital-acquired, central line-associated bloodstream infections Denominator: Number of Acute Care central line catheter days
Data Sources
NHSN Recommended team members
Quality staff
Infection Preventionist
Providers
Department Managers/Directors
Frontline staff
Patient and Families
Lab
Tips and Tricks
Assemble an interdisciplinary team and develop an aim statement that reflects your organization's CLABSI goals
Educate and ensure that CLABSI education is provided at new employee
orientation and ongoing education throughout the year (Ex. Monthly staff meetings
and competency/skill fairs)
Participate in the HAI Community of Practice
Include discussion of patients with central line catheters in place at your daily
huddles and get them out if possible
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Confer your rights to IHC in NHSN
Educate patients and families about CLABSI and how it can be prevented
Resources
HRET Top Ten Checklist for CLABSI Checklist to review current interventions or initiate new interventions CDC Device-associated Module - BSI Bloodstream Infection Event (Central Line-Associated Bloodstream Infection and NON-central line-associated Bloodstream Infection) Checklist for Prevention of Central Line Associated Blood Stream Infections Checklist for providers and facilities
Institute for Healthcare Improvement How-to Guide: Prevent Central Line-Associated Bloodstream Infections, page 22. (Login required with free access to information)
FAQs About Catheter Associated Bloodstream Infections This CDC fact sheet can be used to educate patients about CLABSI. This fact sheet is also available in Spanish. To access the Spanish version of this fact sheet, click this link
CLABSI SIR (Standardized Infection Ratios) will be obtained from NHSN information
conferred to IHC and included in the analysis of statewide and national results for each
eligible facility and reported for two cohorts – one for ICUs and another for ICUs with
Other Reporting Units.
Process Measures:
Central Line Utilization Ratio Numerator: Number of central line days Denominator: Total number of patient days
Data Sources
NHSN
Recommended team members
Quality staff
Infection Preventionist
Providers
Department Managers/Directors
Frontline staff
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Patient and Families
Lab
Tips and Tricks
Include discussion of patients with central line catheters in place at your daily huddles and get them out if possible
Confer your rights to IHC in NHSN
Remove Central Lines as soon as they are not medically necessary
Resources
Joint Commission CVC Maintenance Bundles
Maintenance Bundles to reduce CLABSI Rates
Central Line Insertion Compliance
Numerator: Number of Acute Care, Skilled Nursing Facility and Swing Bed inpatients with full PICC line and/or central line catheter insertion bundle compliance Denominator: Number of Acute Care, Skilled Nursing Facility and Swing Bed inpatients with PICC line and/or central line insertions
Data Sources
Self-Reported
Recommended team members
Quality staff
Infection Preventionist
Providers
Department Managers/Directors
Frontline staff
Patient and Families
Lab Tips and Tricks
Request IT build the CVC insertion and maintenance bundles into your EHR and have the nurse complete while the provider inserts the central line or maintaining the line
Adapt a central line insertion checklist to your organization and pilot its use
Avoid femoral insertion of central lines whenever possible
Bundle supplies to ensure central line supplies are readily available for use when needed
Resources
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Joint Commission CVC Insertion Bundles
Insertion bundle components
CDC Checklist for Prevention of Central Line Associated Blood Stream Infections
Includes insertion, maintenance and hospital specific interventions
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Falls and Immobility Falls are the most commonly reported incidents within the healthcare setting and can increase patient risk for hospital-acquired injuries and/or immobility. If the patient is immobile, this may prolong hospitalization and decrease the patients’ ability to function. These measures look at inpatient falls resulting in fracture or dislocation, no injury, minor injury, moderate injury, major injury, death, count of assisted falls, and fall risk assessment. See below for more detailed information about each measure. These measures help to determine how many and how often patients are falling in the inpatient setting as well as how many are harmed by falls.
Measures Outcome Measures: Fall Resulting in Fracture or Dislocation (CMS HAC)
Numerator: Number of Acute Care inpatient discharges with ICD-9/10 fracture or dislocation code(s) not present on admission
Denominator: Number of Acute Care discharges
Data Sources
IPOP/Claims Data (where available)
Self-Reported
Recommended team members
Quality staff
Providers
Pharmacist
Department Managers/Directors
Frontline staff
Patient and Families
Health Coach
Social Worker/Case Manager
HIM
Nursing Home
Home Care
Hospice
Physical/Occupational/Speech Therapy staff
Doctor office/Clinic staff
Tips and Tricks
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Assemble an interdisciplinary team and develop an aim statement that reflects your organization's Fall Prevention goals
Educate and ensure that Fall Prevention education is provided at new employee
orientation and ongoing education throughout the year (Ex. Monthly staff
meetings and competency/skill fairs)
Participate in the HIIN Fall Prevention Community of Practice
Engage leadership on the importance of creating a just culture that allows front-line empowered to fill out incidents reports when falls occur
Include discussion of patients with fall risk at your daily huddles and individualize
their interventions for safety
Support teams in posting their “days since last fall” data
Implement Intentional rounding
Educate on and implement Post fall huddles
Show the falls videos from the Iowa Fall Prevention Task Force on your facility TV Station
Adjust your staffing according to fall risk acuity
Implement the “no pass rule” for all employees
Consider sleep cycles for inpatients. Improve light and sound levels during the night and encourage patient to be awake and active during the day if possible
Resources
HRET Top Ten Checklist for Fall Prevention Checklist to review current or initiate new interventions for fall prevention IHC HEN Falls-Dislocation Codes Complete list of ICD-10 Codes for Falls Institute for Healthcare Improvement Transforming Care at the Bedside How-to Guide: Reducing Patient Injuries from Falls (Login required with free access to information) CMS Hospital Acquired Conditions ICD-10 Codes for Falls Agency for Healthcare Research and Quality (AHRQ) Bundle of Interventions Targeting High-Risk Patients Reduces Falls and Fall-Related Injuries on Medical-Surgical Units Medscape – Managing Falls in Older People With Cognitive Impairment Patient Safety Authority
Hospital Engagement Network Falls Reduction and Prevention Collaboration Self-Assessment Tool
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Falls Prevention Process Measures Audit Tool Pennsylvania Hospital Engagement Network: Falls Reduction and Prevention Investigation Tool
Iowa Falls Prevention Coalition Videos Great for using on your facility channels. 6 videos: Falls Prevention: An Overview, In-Home Fall Hazards, Environmental/Outside Fall Hazards, Medication and Falls: How to Reduce Your Risk of Falling, Vision and Falls: How to Reduce Your Risk of Falling and Exercise and Balance for Falls Prevention
*Fall Resulting in No Apparent Injury Rate
Numerator: Number of falls for Acute Care, Skilled Nursing Facility, Swing Bed and Observation patients that have unplanned descent to the floor resulting in no visible sign of injury, stable vital signs and patient denial or pain or discomfort
Denominator: Number of patient days for Acute Care, Skilled Nursing Care, Swing Bed and Observation patient days - exclude newborn and respite patients
Data Sources
Self-Reported
Recommended team members
Quality staff
Providers
Pharmacist
Department Managers/Directors
Frontline staff
Patient and Families
Health Coach
Social Worker/Case Manager
Clinical IT
Nursing Home
Home Care
Hospice
Physical/Occupational/Speech Therapy staff
Doctor office/Clinic staff
Tips and Tricks
“0” denominator not allowed
*Fall Resulting in Minor Injury Rate
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Numerator: Number of for Acute Care, Skilled Nursing Facility, Swing Bed and Observation patients that have unplanned descent to the floor resulting in minor cuts, minor bleeding, minor skin abrasions, minor swelling and minor contusions or bruising
Denominator: Number of patient days for Acute Care, Skilled Nursing Care, Swing Bed and Observation patient days - exclude newborn and respite patients
Data Sources
Self-Reported
Recommended team members
Quality staff
Providers
Pharmacist
Department Managers/Directors
Frontline staff
Patient and Families
Health Coach
Social Worker/Case Manager
Clinical IT
Nursing Home
Home Care
Hospice
Physical/Occupational/Speech Therapy staff
Doctor office/Clinic staff
Tips and Tricks
“0” denominator not allowed
Severity of patient injury (as defined by the National Quality Forum): Minor: Injury that results in application of dressing, ice, cleaning of a wound, limb elevation, or topical medication
*Fall Resulting in Moderate Injury Rate
Numerator: Number of for Acute Care, Skilled Nursing Facility, Swing Bed and Observation patients that have unplanned descent to the floor resulting in excessive bleeding, lacerations requiring sutures, temporary loss of consciousness or moderate head trauma
Denominator: Number of patient days for Acute Care, Skilled Nursing Care, Swing Bed and Observation patient days - exclude newborn and respite patients
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Data Sources
Self-Reported
Recommended team members
Quality staff
Providers
Pharmacist
Department Managers/Directors
Frontline staff
Patient and Families
Health Coach
Social Worker/Case Manager
Clinical IT
Nursing Home
Home Care
Hospice
Physical/Occupational/Speech Therapy staff
Doctor office/Clinic staff
Tips and Tricks
“0” denominator not allowed
Severity of patient injury (as defined by the National Quality Forum): Moderate: Injury that results in suturing, steri-strips, fracture, or splinting
*Fall Resulting in Major Injury Rate
Numerator: Number of for Acute Care, Skilled Nursing Facility, Swing Bed and Observation patients that have unplanned descent to the floor resulting in fracture, subdural hematoma, other major head trauma, cardiac arrest or patient requiring transfer to ICU or OR
Denominator: Number of patient days for Acute Care, Skilled Nursing Care, Swing Bed and Observation patient days - exclude newborn and respite patients
Data Sources
Self-Reported
Recommended team members
Quality staff
Providers
Pharmacist
Department Managers/Directors
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Frontline staff
Patient and Families
Health Coach
Social Worker/Case Manager
Clinical IT
Nursing Home
Home Care
Hospice
Physical/Occupational/Speech Therapy staff
Doctor office/Clinic staff
Tips and Tricks
“0” denominator not allowed
Severity of patient injury (as defined by the National Quality Forum): Major: Injury that results in surgery, casting, or traction
*Fall Resulting in Death Rate
Numerator: Number of for Acute Care, Skilled Nursing Facility, Swing Bed and Observation patients that have unplanned descent to the floor resulting in death
Denominator: Number of patient days for Acute Care, Skilled Nursing Care, Swing Bed and Observation patient days - exclude newborn and respite patients
Data Sources
Self-Reported
Recommended team members
Quality staff
Providers
Pharmacist
Department Managers/Directors
Frontline staff
Patient and Families
Health Coach
Social Worker/Case Manager
Clinical IT
Nursing Home
Home Care
Hospice
Physical/Occupational/Speech Therapy staff
Doctor office/Clinic staff
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Tips and Tricks
“0” denominator not allowed
Severity of patient injury (as defined by the National Quality Forum Death: Death as a result of a fall
*Do not include patients assisted or eased to the floor
Count of Assisted Falls
Numerator: Number of Acute Care, Skilled Nursing Facility, Swing Bed and Observation events where the patient is assisted or eased to the floor
Denominator: No denominator for this measure
Data Sources
Self-Reported
Recommended team members
Quality staff
Providers
Pharmacist
Department Managers/Directors
Frontline staff
Patient and Families
Health Coach
Social Worker/Case Manager
Clinical IT
Nursing Home
Home Care
Hospice
Physical/Occupational/Speech Therapy staff
Doctor office/Clinic staff
Tips and Tricks
Ensure that when a patient fall is included in this category that it is not counted in any other category
Process Measures:
Fall Risk Assessment on Admission
Numerator: Number of Acute Care, Skilled Nursing Facility, Swing Bed and Observation patients assessed for fall risk on admission
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Denominator: Number of Acute Care, Skilled Nursing Facility, Swing Bed and Observation patients admitted
Data Sources
Self-Reported
Recommended team members
Quality staff
Providers
Pharmacist
Department Managers/Directors
Frontline staff
Patient and Families
Health Coach
Social Worker/Case Manager
Clinical IT
Nursing Home
Home Care
Hospice
Physical/Occupational/Speech Therapy staff
Doctor office/Clinic staff
Tips and Tricks
Educate and ensure that fall risk assessment education is provided at new
employee orientation and ongoing education throughout the year (Ex. Monthly
staff meetings and competency/skill fairs)
Include the family in discussions on patient safety and normal bathroom and sleep schedules
Initial fall risk assessment should be completed upon admission and recommended to reassess every shift or with any change of condition
Resources
AHRQ – Quality Tool Fall TIPS (Tailoring Interventions for Patient Safety) Morse Fall Scale competency manual, fall prevention behavior scale, fall prevention self-efficacy scale Morse Fall Scale Morse Fall Scale, with information on patient safety factors and patient education
Fall Risk Assessment for Older Adults: The Hendrich II Fall Risk Model Providers can use this fall risk assessment tool, intended for the acute care setting, to reduce falls by identifying individual risks for falls
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CDC Steadi Toolkit Materials for providers and patients. Checklists, brochures, education, algorithm for fall assessment and interventions, video for tug test, 30 second chair stand test and 4 stage balance test
Iowa Falls Prevention Coalition Videos Great for using on your facility channels. 6 videos: Falls Prevention: An Overview, In-Home Fall Hazards, Environmental/Outside Fall Hazards, Medication and Falls: How to Reduce Your Risk of Falling, Vision and Falls: How to Reduce Your Risk of Falling and Exercise and Balance for Falls Prevention
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Pressure Ulcers Pressure ulcers occur frequently within the hospital setting. Pressure ulcers are staged on severity and are localized to the skin and tissue. These measures look at the number of inpatients (Acute Care, Skilled Nursing, Swing Bed) receiving full preventive care and the number who have a pressure ulcer diagnosis code. See below for more detailed information about each measure. These measures help to determine how many patients are harmed by pressure ulcers.
Measures
Outcome Measure: Pressure Ulcer Rate, Stage 3+ (AHRQ)
Numerator: Number of Acute Care, Skilled Nursing Facility and Swing Bed inpatients with ICD-9/10 code(s) for pressure ulcer AND secondary ICD-9/10 diagnosis code(s) for Stage III, Stage IV or unstageable pressure ulcer, non-POA
Denominator: Number of at-risk Acute Care, Skilled Nursing Facility and Swing Bed inpatients
Data Sources
IPOP/Claims Data (where available)
Self-Reported
Recommended team members
Quality staff
Providers
Department Managers/Directors
Frontline staff
Patient and Families
Health Coach
Social Worker/Case Manager
Clinical IT
HIM
Nursing Home
Home Care
Hospice
Wound/ostomy staff
Physical/Occupational/Speech Therapy staff
Doctor office/Clinic staff
Dietitian
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Tips and Tricks
Refer to AHRQ PSI 3 technical specifications for exclusions
Assemble an interdisciplinary team and develop an aim statement that reflects your organization's Pressure Ulcer goals
Educate and ensure that Pressure Ulcer education is provided at new employee
orientation and ongoing education throughout the year (Ex. Monthly staff
meetings and competency/skill fairs)
Include discussion of patients with pressure ulcers at your daily huddles and
ensure they are receiving the full pressure ulcer preventative care
Ensure that your providers and nurses are consistent with documentation of pressure ulcers
Resources
HRET Top Ten Checklist for Pressure Ulcer Checklist to review current or initiate new interventions for HAPU prevention National Pressure Ulcer Advisory Panel NPUAP Pressure Ulcer Stages/categories ARHQ – Preventing Pressure Ulcers in Hospitals Skin assessment, pressure ulcer risk assessment and planning and implementation ideas
National Pressure Ulcer Advisory Panel - Quick Reference Guide Prevention, Interventions and Treatment of Pressure Ulcers Agency for Healthcare Research and Quality (AHRQ) Pressure Ulcer Rate Patient Safety Indicators #3
Process Measure: At-Risk Patients Receiving Full Pressure Ulcer Preventative Care
Numerator: Number of at-risk Acute Care, Skilled Nursing Facility and Swing Bed inpatients receiving full pressure ulcer preventative care
Denominator: Number of at-risk Acute Care, Skilled Nursing Facility and Swing Bed inpatients
Data Sources
Self-Reported
Recommended team members
Quality staff
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Providers
Department Managers/Directors
Frontline staff
Patient and Families
Health Coach
Social Worker/Case Manager
Clinical IT
Wound/ostomy staff
Physical/Occupational/Speech Therapy staff
Dietitian
Tips and Tricks
Educate and ensure that Braden scale and pressure ulcer preventative care
education is provided at new employee orientation and ongoing education
throughout the year (Ex. Monthly staff meetings and competency/skill fairs)
Proper pressure ulcer care includes the following six components: o Conduct a pressure ulcer admission assessment for all patients o Reassess risk daily for every patient o Inspect skin daily o Manage moisture: keep the patient dry and moisturize the skin o Optimize nutrition and hydration o Minimize pressure (Turn/Reposition every two hours and use pressure-
redistribution surfaces)
This measure follows an “all-or-none” format. All components must be performed (or contraindications documented) for compliance to be recorded
Request that IT build the pressure ulcer care components into your EHR
Resources
Braden Scale Instructions and scoring Institute for Healthcare Improvement How-to Guide: Prevent Pressure Ulcers (Login required with free access to information)
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Readmissions and Care Coordination Readmissions are defined as several admissions, inpatient stays, to a hospital or
multiple hospitals by one patient within 30 days.
These measures look at the internal processes (e.g. patient teach-back and
communications) used to reduce hospital readmissions, as well as outcome measures,
looking at the number of acute care inpatient discharges meeting the all-cause 30-day
readmission criteria.
These measures help to determine how many and how often patients are readmitted.
Measures Outcome Measures: Unplanned All-Cause, 30-Day Readmissions to Any Hospital
Numerator: Number of Acute Care inpatient discharges that meet criteria inclusion as a readmission to any hospital using unplanned, 30- day, all-cause, all-payer methodology
Denominator: Number of Acute Care Inpatient discharges meeting eligibility for inclusion as an index admission Data Sources
IPOP/Claims Data (where available)
Self-Reported
Recommended team members
Quality staff
Providers
Pharmacist
Department Managers/Directors
Frontline staff
Patient and Families
Health Coach
Social Worker/Case Manager
HIM
Nursing Home
Home Care
Tips and Tricks
Claims based data or IPOP data: To get data that is real time make sure your readmission claims are being submitted monthly, talk with you IPOP submitter about monthly vs. quarterly submissions
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Assemble an interdisciplinary team and develop an aim statement that reflects your organization's Care Transition goals
Partner with family caregivers in the hospital, to help ensure safe transitions
Develop and lead a Community Care Coalition
Ensure that prescriptions are filled prior to discharge
Include Pharmacist in medication reconciliation and education upon admission and discharge
Encourage patient participation in developing a discharge planning tool to reinforce the discharge plan
Implement system for follow up phone calls to discharged patients within 24-72 hours of discharge
Remove exclusions from your numerator population (planned readmissions like chemotherapy, radiation, rehab, planned surgery, renal dialysis). The number of (index) discharges that resulted in readmissions within 30 days will be your numerator
Remove exclusions from the denominator population (transfers to other acute care, deceased before discharge, Labor and Delivery). The number of discharges after you remove the exclusions is your denominator (or “index discharges”)
Resources HRET Top Ten Checklist for Readmissions A checklist to review current, or initiate new interventions to prevent avoidable readmissions in your facility
IHI Effective Interventions to Reduce Rehospitalizations Includes: RED: Re-Engineered Discharge, Transitional Care Model, Care Transitions Program and many more ways to help with discharges
AHA HRET Hospital Engagement Network – Resources Resources to drive improvement in Preventable Readmissions – Suggested resources: Hospital Guide to Reducing Medicaid Readmissions AHRQ; Risk Assessment tools, Preventable Readmission. Change Package; Preventable Readmission Checklist, click on topics and choose readmissions
Center for Healthcare Research and Transformation – Care Transitions: Best Practices and Evidence-based Programs Best practices in Care Transitions
Institute for Healthcare Improvement Overview State Action on Avoidable Re-hospitalizations – STAAR Model Unplanned All-Cause, 30-Day Readmission to the Same Hospital
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Numerator: Number of Acute Care inpatient discharges that meet criteria inclusion as a readmission to the same hospital using unplanned, 30-day, all-cause, all-payer methodology
Denominator: Number of Acute Care inpatient discharges meeting eligibility for inclusion as an index admission Data Sources
IPOP/Claims data (where available) Self-reported
Recommended team members
Quality staff
Providers
Pharmacist
Department Managers/Directors
Frontline staff
Patient and Families
Health Coach
Social Worker/Case Manager
HIM
Nursing Home
Home Care
Tips and Tricks
Claims based data or IPOP data: To get data that is real time make sure your readmission claims are being submitted monthly, talk with you IPOP submitter about monthly vs. quarterly submissions
Assemble an interdisciplinary team and develop an aim statement that reflects your organization's Care Transition goals
Partner with family caregivers in the hospital, to help ensure safe transitions
Develop and lead a Community Care Coalition
Fill prescriptions prior to discharge
Include Pharmacist in medication reconciliation and education upon admission and discharge
Encourage patient participation in developing a discharge planning tool to reinforce the discharge plan
Implement system for follow up phone calls to discharged patients within 24-72 hours of discharge
Remove exclusions from your numerator population (planned readmissions like chemotherapy, radiation, rehab, planned surgery, renal dialysis). The number of (index) discharges that resulted in readmissions within 30 days will be your numerator
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Remove exclusions from the denominator population (transfers to other acute care, deceased before discharge, Labor and Delivery). The number of discharges after you remove the exclusions is your denominator (or “index discharges”)
Resources HRET Top Ten Checklist for Readmissions A checklist to review current, or initiate new interventions to prevent avoidable readmissions in your facility
AHA HRET Hospital Engagement Network – Resources Resources to drive improvement in Preventable Readmissions – Suggested resources: Hospital Guide to Reducing Medicaid Readmissions AHRQ; Risk Assessment tools, Preventable Readmission. Change Package; Preventable Readmission Checklist, click on topics and choose readmissions
IHI Effective Interventions to Reduce Rehospitalizations Includes: RED: Re-Engineered Discharge, Transitional Care Model, Care Transitions Program and many more ways to help with discharges
Center for Healthcare Research and Transformation – Care Transitions: Best Practices and Evidence-based Programs Best practices in Care Transitions
Institute for Healthcare Improvement Overview State Action on Avoidable Re-hospitalizations – STAAR Model
Process Measures: Patient Teach-Back
Numerator: Number of observations of nurses where teach-back is used to assess understanding
Denominator: Number of observations of nurse teaching
Data Sources
Self-Reported
Recommended team members
Quality staff
Providers
Pharmacist
Department Managers/Directors
Frontline staff
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Patient and Families
Health Coach
Social Worker/Case Manager
Tips and Tricks
Educate and ensure that Teach-back education is provided at new employee
orientation and ongoing education throughout the year (Ex. Monthly staff
meetings and competency/skill fairs)
Utilize the suggested teach-back questions to patients to make sure they understand discharge instructions
Assessment can be provided via direct observation or someone other than the discharge nurse can go in and assess the patient and family understanding for teach-back
Resources Can Teach-back Reduce Hospital Readmissions Teach-back essentials
AHRQ Health Literacy Universal Precautions Toolkit, 2nd Edition Teach-back and health literacy information, includes a Teach-Back Observation Tool!
Always Use Teach-back Toolkit that includes interactive teach-back learning modules, coaching to always use teach-back, resources and videos
Community Provider Involvement in Identifying Post-Discharge Needs Numerator: Number of Acute Care, Skilled Nursing Facility and Swing Bed inpatient discharges where community providers (e.g. home care, primary care, nurses, skilled nursing) were included in assessing post discharge needs
Denominator: Number of discharges for Acute Care, Skilled Nursing Care and Swing Bed inpatient discharges
Data Sources
Self-Reported
Recommended team members
Quality staff
Providers
Pharmacist
Department Managers/Directors
Frontline staff
Patient and Families
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Health Coach
Social Worker/Case Manager
Physical/Occupational/Speech Therapy
Dietitian
Nursing Home
Home Care
Hospice
Tips and Tricks
Ensure that the patient to be discharged is assessed for ongoing needs after discharge
This measure is met by including at least one of the providers in parentheses, you do not need all resources listed
Include documentation of communication of a discharge plan discussed with one of the community providers listed or have the community provider document their participation
Resources Becker’s Infection Control and Clinical Quality, Why Improving Communication May Be the Key to Reducing Readmissions Preventing readmissions by including post-acute care providers in the discharge plan
Post-Hospital Follow-Up Appointment
Numerator: Number of Acute Care, Skilled Nursing Facility and Swing Bed inpatient discharges with follow-up appointment scheduled before discharge in accordance with risk assessment Denominator: Number of discharges for Acute Care, Skilled Nursing Care and Swing Bed inpatient discharges
Data Sources
Self-reported Recommended team members
Quality staff
Providers
Pharmacist
Department Managers/Directors
Frontline staff
Patient and Families
Health Coach
Social Worker/Case Manager
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Tips and Tricks
Develop and implement a system for evenings, weekends and holidays and follow up on the next business day, this will meet the measure
Develop a system to ensure the communication loop has been closed and the patient has an appointment from the clinic
Ensure the discharge appointment process is someone’s responsibility, delegating this responsibility with ensure consistency of the process
Use the LACE readmissions risk assessment tool to determine readmission risk classification and associated timeline for follow-up appointment
Recommended follow-up time frames: o High risk 3-5days o Moderate risk 5-7 days o Low or no risk 7-14 days
Ensure physician documentation is provided if no follow-up is necessary Resources Lace Tool
Society of Hospital Medicine – Follow-up Appointments Project BOOST Implementation Toolkit Tools and implementation tips for follow-up appointments
Handover Communication
Numerator: Number of Acute Care, Skilled Nursing Facility and Swing Bed inpatient discharges where critical information is transmitted to the next site of care (e.g. office, PCP, LTC, HH) or person continuing care
Denominator: Number of discharges for Acute Care, Skilled Nursing Care and Swing Bed inpatient discharges
Data Sources
Self-Reported Recommended team members
Quality staff
Providers
Department Managers/Directors
Frontline staff
Patient and Families
Health Coach
Social Worker/Case Manager
Doctor Office/Clinic Staff
Nursing Home
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Home Care
Hospice Tips and Tricks
Educate staff on hospitals standardized approach to handover communication
Critical information includes: ***Vital signs, medication list, allergies, daily habits (bathroom, ambulatory, dietary, sleep), fall risk, available lab and test results
Ensure system for sending pending lab and test results once they are available if not available at the time of transfer
Resources AHRQ Handoffs and Signouts Includes inpatient and discharge handovers. I-PASS study
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Severe Sepsis and Septic Shock Sepsis is an inflammatory response to infection and can be life-threatening. Sepsis is also referred to as “blood poisoning.” Measures focus on diagnosis of Sepsis (Postoperative sepsis and sepsis rate) and severe sepsis and septic shock management bundle compliance. The current NHSN Manual – Patient Safety Component is utilized for defining and reporting on these measures. To access the manual, follow this link: http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf. See below for more detailed information about each measure. These measures will help to determine how many and how often patients are harmed by Sepsis.
Measures
Outcome Measure: Postoperative Sepsis Rate, (AHRQ PSI 13)
Numerator: Number of Acute Care elective surgical inpatient discharges with any secondary ICD-9/10 diagnosis code for sepsis
Denominator: Number of Acute Care elective surgical inpatient discharges with any-listed ICD-9/10 procedure code for an operating room procedure and admission type recorded as elective
Data Sources
IPOP/Claims Data (where available)
Self-Reported
Recommended team members
Quality staff
Infection Preventionist
Providers
Pharmacist
Department Managers/Directors
Frontline staff
Patient and Families
Health Coach
Social Worker/Case Manager
HIM
Nursing Home
Home Care
Hospice
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Wound/ostomy staff
Lab
Doctor office/Clinic staff
Dietitian
Tips and Tricks
Assemble an interdisciplinary team and develop an aim statement that reflects your organization's Sepsis goals
Educate and ensure that Sepsis education is provided at new employee
orientation and ongoing education throughout the year (Ex. Monthly staff
meetings and competency/skill fairs)
Participate in the HAI Community of Practice
Resources HRET Top Ten Checklist for Sepsis Checklist to review current or initiate new sepsis mortality reduction interventions NQF-Endorsed Voluntary Consensus Standard for Hospital Care Measure information collected for: CMS Voluntary Only – Surgical Care Improvement Project (SCIP) AHRQ Selected Best Practices and Suggestions for Improvement PSI 13: Postoperative Sepsis Recommended practices, best processes, and educational recommendations
Process Measures: Severe Sepsis and Septic Shock 3-hour Management Bundle Compliance (NQF 0500)
Numerator: Number of Acute Care, Skilled Nursing Facility and Swing Bed inpatients in the denominator population who receive all elements of the 3 hour Severe Sepsis and Septic Shock Management Bundle
Denominator: Number of Acute Care, Skilled Nursing Facility and Swing Bed inpatients presenting with severe sepsis or septic shock (exclude patients comfort care only, where central line cannot be placed or is contraindicated, or where clinical condition precludes total measure completion)
Data Sources
Self-Reported
Recommended team members
Quality staff
Infection Preventionist
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Providers
Pharmacist
Department Managers/Directors
Frontline staff
Patient and Families
Clinical IT
Lab
Doctor office/Clinic staff
Tips and Tricks
Assemble an interdisciplinary team and develop an aim statement that reflects your organization's Sepsis goals
Educate and ensure that Sepsis bundle education is provided at new employee
orientation and ongoing education throughout the year (Ex. Monthly staff
meetings and competency/skill fairs)
Include discussion of patients at risk or diagnosed with Sepsis at your daily
huddles
Severe Sepsis Screening
o Is the patient’s history suggestive of a new infection?
o Are 2 of the following new to the patient and present?
Hyperthermia > 38.3 Celsius
Hypothermia < 36 Celsius
Altered mental status
Tachycardia > 90 bpm
Tachypnea > 20 bpm
Leukocytosis (WBC > 12000)
Leukopenia (WBC count< 4000)
Hyperglycemia (Plasma glucose > 140 mg/dl) or 7.7 mmol/L in the absence
of diabetes
If answer is yes to the above 2 questions, suspicion of infection is present
o Organ dysfunction criteria
SBP < 90 mmHg or MAP <65 mmHg
SBP decrease > 40 mmHg from baseline
Creatinine > 2.0 mg/dl or urine output < 0.5 ml/kg/hour for 2 hours
Bilirubin > 2 mg/dl
Platelet count < 100,000
Lactate > 2 mmol/L
INR >1.5 or PTT > 60 secs
Acute lung injury with a PaO2/Fio2 <250 in the absence of pneumonia as an
infection source
Acute lung injury with a PaO2/Fio2 <200 in the presence of pneumonia as an
infection source
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If suspicion of infection and organ dysfunction is present, the patient meets
criteria for Severe Sepsis
This measure is for inpatients and excludes ER. We encourage you to implement all bundles into ER as well as inpatients
Request that IT build a Sepsis alert into your triage, admission and nursing assessments
Develop a tracking sheet for every person screened with sepsis at triage and/or admission to stay on their chart until discharge or have the order sets built into EHR
Ensure the 2nd lactate is ordered the same time as the first lactate
Educate Patients and Families on how to recognize sepsis in yourself and family members
Utilize the Surviving Sepsis Campaign Implementation Guide
Resources
Sepsis Bundle Project (SEP) – National Hospital Inpatient Quality Measures SEP Measure Set Table, last updated version 5.0a. Sepsis initial patient population algorithm
Surviving Sepsis Campaign Updated Bundles in Response to New Evidence Surviving Sepsis Campaign – Tool Evaluation for Severe Sepsis Screening Tool
Evaluation for Severe Sepsis Screening Tool This is an optional tool to assist in screening patients for severe sepsis within three patient care settings: the emergency department, medical/surgical floors, or in the ICU
Severe Sepsis and Septic Shock 6-hour Management Bundle Compliance (NQF 0500)
Numerator: Number of Acute Care, Skilled Nursing Facility and Swing Bed inpatients in the denominator population who receive all elements of the 6-hour Severe Sepsis and Septic Shock Management Bundle
Denominator: Number of Acute Care, Skilled Nursing Facility and Swing Bed inpatients presenting with severe sepsis or septic shock (exclude patients comfort care only, where central line cannot be placed or is contraindicated, or where clinical condition precludes total measure completion)
Data Sources
Self-Reported
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Recommended team members
Quality staff
Infection Preventionist
Providers
Pharmacist
Department Managers/Directors
Frontline staff
Patient and Families
Clinical IT
Lab
Doctor office/Clinic staff
Tips and Tricks
Assemble an interdisciplinary team and develop an aim statement that reflects your organization's Sepsis goals
Educate and ensure that Sepsis bundle education is provided at new employee orientation and ongoing education throughout the year (Ex. Monthly staff meetings and competency/skill fairs)
Include discussion of patients at risk or diagnosed with Sepsis at your daily huddles
This measure is for inpatients and excludes ER. We encourage you to implement all bundles into ER as well as inpatients
Request that IT build a Sepsis alert into your triage, admission and nursing assessments
Develop a tracking sheet for every person screened with sepsis at triage and/or admission to stay on their chart until discharge or have the order sets built into EHR
Ensure the 2nd lactate is ordered the same time as the first lactate
Educate Patients and Families on how to recognize sepsis in yourself and family members
Utilize the Surviving Sepsis Campaign Implementation Guide
Resources
Sepsis Bundle Project (SEP) – National Hospital Inpatient Quality Measures SEP Measure Set Table, last updated version 5.0a. Sepsis initial patient population algorithm
Surviving Sepsis Campaign Updated Bundles in Response to New Evidence Surviving Sepsis Campaign – Tool Evaluation for Severe Sepsis Screening Tool
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Surgical Site Infection (SSI) A surgical site infection (SSI) occurs after a surgery, in the part of the body where the surgery took place. Surgical site infections can sometimes be superficial infections only involving the skin. Other SSIs are more serious and can involve tissues under the skin, organs, or implanted material. The process measures look at surgical safety checklist compliance and temperature management. The Outcome measures focus on infection rates per number of surgical episodes. See below for more detailed information about each measure. The current NHSN Manual – Patient Safety Component is utilized for defining and reporting on these measures. To access the manual, follow this link: http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf. These measures help to determine how many patients are harmed by SSIs.
Measures Outcome Measures: Colon Surgical Site Infection Rate
Numerator: Number of hospital-acquired colon surgical site infections
Denominator: Number of colon surgical episodes
Data Sources
NHSN
Recommended team members
Quality staff
Infection Preventionist
Providers
Department Managers/Directors
Frontline staff
Patient and Families
Lab
HIM
Doctor office/Clinic staff
Tips and Tricks
Report when your facility performs 10 or more Colon surgeries in a year
Assemble an interdisciplinary team and develop an aim statement that reflects your organization's SSI goals
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Educate and ensure that SSI education is provided at new employee orientation
and ongoing education throughout the year (Ex. Monthly staff meetings and
competency/skill fairs)
Participate in the HAI Community of Practice
Develop a system to provide consistent SSI reporting from Surgeons
Provide patient and family education on SSI and how they can be prevented
Avoid using flash sterilization for convenience, as an alternative to purchasing additional instrument sets, or to save time
Ensure clinical practice aligns with the most recent guidelines for antimicrobial prophylaxis in surgery
Utilize TeamSTEPPS tools such as "check back" when communicating with other health care professionals
Resources
HRET Top Ten Checklist for SSI
CDC Surgical Site Infection Event
ICD-10 PCS and CPT Mapping, wound classes, SSI criteria and SSI event reporting
instructions
AHRQ Postoperative Sepsis Rate PSI #13
ICD-9 and ICD-10 codes and descriptions
CDC Surgical Site Infection SSI Event
Surgical Site Infection (SSI) Toolkit
CDC Toolkit is organized as a PowerPoint document and includes SSI prevention
strategies
Frequently Asked Questions About Surgical Site Infections
The CDC provides answers to the most frequently asked questions about SSIs
Abdominal Hysterectomy Surgical Site Infection Rate
Numerator: Number of hospital-acquired abdominal hysterectomy surgical site infections
Denominator: Number of abdominal hysterectomy surgical episodes
Data Sources
NHSN
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Recommended team members
Quality staff
Infection Preventionist
Providers
Department Managers/Directors
Frontline staff
Patient and Families
Lab
HIM
Doctor office/Clinic staff
Tips and Tricks
Report when your facility performs 10 or more Abdominal Hysterectomy surgeries in a year
Assemble an interdisciplinary team and develop an aim statement that reflects your organization's SSI goals
Educate and ensure that SSI education is provided at new employee orientation
and ongoing education throughout the year (Ex. Monthly staff meetings and
competency/skill fairs)
Develop a system to provide consistent SSI reporting from Surgeons
Provide patient and family education on SSI and how they can be prevented
Avoid using flash sterilization for convenience, as an alternative to purchasing additional instrument sets, or to save time
Ensure clinical practice aligns with the most recent guidelines for antimicrobial prophylaxis in surgery
Utilize TeamSTEPPS tools such as "check back" when communicating with other health care professionals
Resources HRET Top Ten Checklist for SSI
CDC Surgical Site Infection Event
ICD-10 PCS and CPT Mapping, wound classes, SSI criteria and SSI event reporting
instructions
AHRQ Postoperative Sepsis Rate PSI #13
ICD-9 and ICD-10 codes and descriptions
Hip Replacement Surgical Site Infection Rate
Numerator: Number of hospital-acquired hip replacement surgical site infections
Denominator: Number of hip replacement surgical episodes
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Data Sources
NHSN
Recommended team members
Quality staff
Infection Preventionist
Providers
Department Managers/Directors
Frontline staff
Patient and Families
Lab
HIM
Doctor office/Clinic staff
Tips and Tricks
Report when your facility performs 10 or more Hip Replacement surgeries in a year
Assemble an interdisciplinary team and develop an aim statement that reflects your organization's SSI goals
Educate and ensure that SSI education is provided at new employee orientation
and ongoing education throughout the year (Ex. Monthly staff meetings and
competency/skill fairs)
Develop a system to provide consistent SSI reporting from Surgeons
Provide patient and family education on SSI and how they can be prevented
Avoid using flash sterilization for convenience, as an alternative to purchasing additional instrument sets, or to save time
Ensure clinical practice aligns with the most recent guidelines for antimicrobial prophylaxis in surgery
Utilize TeamSTEPPS tools such as "check back" when communicating with other health care professionals
Resources
HRET Top Ten Checklist for SSI
CDC Surgical Site Infection Event
ICD-10 PCS and CPT Mapping, wound classes, SSI criteria and SSI event reporting
instructions
AHRQ Postoperative Sepsis Rate PSI #13
ICD-9 and ICD-10 codes and descriptions
IHI How to Guide: Prevent Surgical Site Infection for Hip and Knee Arthroplasty
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Evidence supporting interventions and how to implement to prevent SSI for hip and
knee arthroplasty
Guide to the Elimination of Orthopedic Surgical Site Infections
This guide created and presented by APIC will help healthcare providers reduce
orthopedic SSIs
Knee Replacement Surgical Site Infection Rate Numerator: Number of hospital-acquired knee replacement surgical site infections
Denominator: Number of knee replacement surgical episodes
Data Sources
NHSN
Recommended team members
Quality staff
Infection Preventionist
Providers
Department Managers/Directors
Frontline staff
Patient and Families
Lab
HIM
Doctor office/Clinic staff
Tips and Tricks
Report when your facility performs 10 or more Knee Replacement surgeries in a year
Assemble an interdisciplinary team and develop an aim statement that reflects your organization's SSI goals
Educate and ensure that SSI education is provided at new employee orientation
and ongoing education throughout the year (Ex. Monthly staff meetings and
competency/skill fairs)
Develop a system to provide consistent SSI reporting from Surgeons
Provide patient and family education on SSI and how they can be prevented
Avoid using flash sterilization for convenience, as an alternative to purchasing additional instrument sets, or to save time
Ensure clinical practice aligns with the most recent guidelines for antimicrobial prophylaxis in surgery
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Utilize TeamSTEPPS tools such as "check back" when communicating with other health care professionals
Resources HRET Top Ten Checklist for SSI CDC Surgical Site Infection Event
ICD-10 PCS and CPT Mapping, wound classes, SSI criteria and SSI event reporting
instructions
AHRQ Postoperative Sepsis Rate PSI #13
ICD-9 and ICD-10 codes and descriptions IHI How to Guide: Prevent Surgical Site Infection for Hip and Knee Arthroplasty
Evidence supporting interventions and how to implement to prevent SSI for hip and
knee arthroplasty
Guide to the Elimination of Orthopedic Surgical Site Infections
This guide created and presented by APIC will help healthcare providers reduce
orthopedic SSIs
Process Measures: Surgery Patients with Perioperative Temperature Management
Numerator: Number of surgical inpatients for whom either active warming was used intraoperatively or who had at least one body temperature equal to or greater than 96.8F/36C within 30 minutes immediately prior to or 15 minutes immediately after anesthesia end time Denominator: Number of surgical inpatients undergoing procedure under general or neuraxial anesthesia of greater than or equal to 60 minutes duration
Data Sources
Self-Reported
Recommended team members
Quality staff
Infection Preventionist
Providers
Department Managers/Directors
Frontline staff
Patient and Families
Clinical IT
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Tips and Tricks
Educate the patient and family prior to the day of surgery of the importance normothermia begins in the home and during the travel to the hospital
Educate hospital staff to keep the patient warm prior to an immediately after surgery and document temperature and interventions accordingly
Resources
HOAJ Perioperative temperature measurement and management
SCIP measurement and maintenance of normothermia. Indications for intraoperative
hypothermia
American Society of Anesthesiologists Perioperative Temperature Management
Preoperative and Intraoperative recommendations and interventions
Surgical Safety Checklist Compliance Numerator: Number of operating room procedures in which the checklist was used
Denominator: Number of operating room procedures during the observed time period
Data Sources
Self-Reported Recommended team members
Quality staff
Infection Preventionist
Providers
Department Managers/Directors
Frontline staff
Patient and Families
Clinical IT
Tips and Tricks
This does not include colonoscopy, endoscopy
Provide staff education of the importance of the surgical safety checklist
Request that IT build the surgical safety checklist into the EHR
Audit annually to ensure the surgical safety checklist is being utilized correctly
Resources
World Health Organization Patient Safety
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Surgical safety checklist and implementation manual
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Ventilator Associated Events (VAE) Ventilator-associated events (VAEs) are events associated to the use of mechanical ventilation in the inpatient setting. These measures look at ventilator bundle compliance and the number of events that meet VAC, IVAC, and possible/probable criteria. See below for more detailed information about each measure. The current NHSN Manual – Patient Safety Component is utilized for defining and reporting on these measures. To access the manual, follow this link: http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf.
These measures help to determine how many and how often patients are harmed by VAEs.
Measures Outcome Measures: Ventilator-Associated Condition (VAC)
Numerator: Number of events that meet VAC criteria
Denominator: Number of ventilator days
Data Sources
NHSN
Recommended team members
Quality staff
Infection Preventionist
Providers
Department Managers/Directors
Frontline staff
Patient and Families
Respiratory/Therapy staff
Physical/Occupational/Speech Therapy staff
Tips and Tricks
Assemble an interdisciplinary team and develop an aim statement that reflects your organization's VAE goals
Educate and ensure that VAE education is provided at new employee orientation
and ongoing education throughout the year (Ex. Monthly staff meetings and
competency/skill fairs)
Participate in the HAI Community of Practice
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Include discussion of patients on mechanical ventilators at your daily huddles
and the progress toward extubation
Ensure your rights are conferred in NHSN to IHC
Avoid intubation and use noninvasive positive pressure ventilation when feasible
Develop a clear understanding of the VAE surveillance definitions and work to partially or completely automate VAE detection
Ensure that the head of the bed is elevated 30 to 45 degrees while visiting your family member who is on ventilator
Implement the ABCDE bundle to prevent delirium, prolonged ventilation and physical deterioration
Resources HRET Top Ten Checklist for VAE Top 10 evidence based interventions CDC Device-associated Module Ventilator-Associated Event (VAE) National Healthcare Safety Network Surveillance for Ventilator-Associated Events - resources for NHSN users already enrolled
Infection-Related Ventilator-Associated Complication (IVAC) Numerator: Number of events that meet IVAC criteria
Denominator: Number of ventilator days
Data Sources
NHSN
Recommended team members
Quality staff
Infection Preventionist
Providers
Department Managers/Directors
Frontline staff
Patient and Families
Respiratory/Therapy staff
Lab
Tips and Tricks
Ensure your rights are conferred in NHSN to IHC
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Include adult locations only
Avoid intubation and use noninvasive positive pressure ventilation when feasible
Develop a clear understanding of the VAE surveillance definitions and work to partially or completely automate VAE detection
Ensure that the head of the bed is elevated 30 to 45 degrees while visiting your family member who is on ventilator
Implement the ABCDE bundle to prevent delirium, prolonged ventilation and physical deterioration
Resources
HRET Top Ten Checklist for VAE Top 10 evidence based interventions CDC Device-associated Module Ventilator-Associated Event (VAE) National Healthcare Safety Network Surveillance for Ventilator-Associated Events - resources for NHSN users already enrolled
Possible/Probable Ventilator-Associated Pneumonia
Numerator: Number of events that meet possible/probable Ventilator- Associated Pneumonia criteria
Denominator: Number of ventilator days
Data Sources
NHSN
Recommended team members
Quality staff
Infection Preventionist
Providers
Department Managers/Directors
Frontline staff
Patient and Families
Respiratory/Therapy staff
Physical/Occupational/Speech Therapy staff
Lab
Tips and Tricks
Ensure your rights are conferred in NHSN to IHC
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Include adult locations only
Avoid intubation and use noninvasive positive pressure ventilation when feasible
Develop a clear understanding of the VAE surveillance definitions and work to partially or completely automate VAE detection
Ensure that the head of the bed is elevated 30 to 45 degrees while visiting your family member who is on ventilator
Implement the ABCDE bundle to prevent delirium, prolonged ventilation and physical deterioration
Resources
Institute for Healthcare Improvement How-to Guide: Prevent Ventilator-Associated Pneumonia, page 27. (Login required with
free access to information)
VAP: Patient and Family Education Sheet
Providers can use this one-page document to help inform patients about the risk of VAP
and prevention strategies utilized in hospitals
Process Measure: Ventilator Bundle Compliance
Numerator: Number of ICU patients in the denominator population on mechanical ventilation with full ventilator-associated prevention bundle compliance
Denominator: Number of ICU patients on mechanical ventilation on day of week of sample
Data Sources
Self-Reported
Recommended team members
Quality staff
Infection Preventionist
Providers
Pharmacist
Department Managers/Directors
Frontline staff
Patient and Families
Respiratory/Therapy staff
Physical/Occupational/Speech Therapy staff
Tips and Tricks
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Educate and ensure that Ventilator Bundle Compliance education is provided at
new employee orientation and ongoing education throughout the year (Ex. Monthly
staff meetings and competency/skill fairs)
Educate staff on the five components of care: o Elevation of the Head (30-45 degrees) o Daily Sedative Interruption and Daily Assessment of Readiness to
Extubate o Peptic Ulcer Disease Prophylaxis o Deep Venous Thrombosis Prophylaxis o Daily Oral Care with Chlorhexidine
This measure follows an “all-or-none” format. All components must be performed (or contraindications documented) for compliance to be recorded
Request that IT builds the five components of care into the EHR
Resources
Institute for Healthcare Improvement
How-to Guide: Prevent Ventilator-Associated Pneumonia, page 10-20. (Login required
with free access to information)
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Venous Thromboembolism (VTE) Venous Thromboembolism (VTE) refers to conditions in which unwanted blood clots form in the body. These clots include both Deep Vein Thrombosis (DVT) and Pulmonary Embolisms (PE). These measures focus on the number post-operative PE or DVT and utilization of appropriate VTE prophylaxis. See below for more detailed information about each measure. These measures help to determine how many and how often patients are harmed by
VTE.
Measures
Outcome Measure:
Post-Operative Pulmonary Embolism (PE) or Deep Venous Thrombosis (DVT) (AHRQ)
Numerator: Number of Acute Care surgical inpatients with non-POA secondary ICD-9/10 code(s) for DVT or PE
Denominator: Number of Acute Care surgical inpatient discharges excluding cases where DVT/PE are present on admission
Data Sources
IPOP/Claims Data (where available)
Self-Reported
Recommended team members
Quality staff
Providers
Pharmacist
Department Managers/Directors
Frontline staff
Patient and Families
Health Coach
Social Worker/Case Manager
HIM
Nursing Home
Home Care
Wound/ostomy staff
Physical/Occupational/Speech Therapy staff
Lab
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Doctor office/Clinic staff
Dietitian
Tips and Tricks
Assemble an interdisciplinary team and develop an aim statement that reflects your organization's VTE goals
Educate and ensure that VTE education is provided at new employee orientation
and ongoing education throughout the year (Ex. Monthly staff meetings and
competency/skill fairs)
Ensure that your Pharmacist is involved
Request that IT builds in a hard stop on risk factors for VTE
Resources
HRET Top Ten Checklist for VTE Top ten evidence based interventions Agency for Healthcare Research and Quality (AHRQ) Perioperative Pulmonary Embolism or Deep Vein Thrombosis Rate, PSI #12
Process Measure:
VTE Appropriate Prophylaxis
Numerator: Number of Acute Care, Skilled Nursing Facility, Swing Bed and Observation patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given
Denominator: Number of admissions to Acute Care, Skilled Nursing Facility, Swing Bed and Observation patients with stays of >48 hours
Data Sources
Self-Reported
Recommended team members
Quality staff
Providers
Pharmacist
Department Managers/Directors
Frontline staff
Patient and Families
Clinical IT
Lab
Dietitian
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Tips and Tricks
If possible, build a hard stop into your EHR for an in
Cover this in daily huddle
Follow your policy on VTE prophylaxis according to your medical director
Distribute provider-level dashboards, allowing providers to see their VTE prophylaxis ordering rates and compare them to other benchmarks
Patient education on Recognizing VTE symptoms and understand VTE treatment options
Design and implement an appropriate VTE protocol with standardized order sets
Pharmacist's role in VTE prevention
Pharmacist-led program to improve venous thromboembolism prophylaxis in a community hospital
Risk Factors for VTE:
o Age over 60 years
o Critical care admission
o Dehydration
o Known thrombophilia
o Obesity
o One or more significant medical comorbidities (heart disease, metabolic, endocrine or
o respiratory pathologies; acute infectious diseases; inflammatory conditions)
o History of VTE
o Use of hormone replacement therapy
o Use of estrogen-containing contraceptive therapy
o Varicose veins with associated phlebitis
o Fracture of pelvis/hip/lower extremity
o Active cancer or cancer treatment
o Indwelling central venous catheter
o Immobility
Resources AHRQ Preventing Hospital-Acquired Venous Thromboembolism Framework for improvement, evidence and best practices, VTE prevention protocol and interventions
AHRQ Quality Indicators Toolkit Selected Best Practices and Suggestions for Improvement, PE and DVT
National Blood Clot Alliance Community members can use this link to access resources from the National Blood Clot Alliance, an organization that is dedicated to DVT/PE prevention. Resources available
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include blood clot education for patients and health professionals, links to news articles, and various events
Venous Thromboembolism (VTE) Risk Assessment (All Patients) Providers can use this VTE risk assessment algorithm from National Health Service (NHS) Choices to assist with VTE risk assessment and to access educational resources for patients and families
Joint Commission VTE 1 VTE measure information form, click on Specifications Manual for National Hospital Inpatient Quality Measures on fist page and then click on Specifications Manual for National Hospital Inpatient Quality Measures v.5.0b. After you download click on the only file showing and find 2j_VTE 1
Venous Thromboembolism Warfarin Therapy Discharge Instructions (CMS VTE-5)
Numerator: Number of patients with documentation that they or their caregivers were given written discharge instructions or other educational material about warfarin
Denominator: Number patients with confirmed VTE discharged on warfarin therapy
Data Sources
Self-Reported
Recommended team members
Quality staff
Providers
Pharmacist
Department Managers/Directors
Frontline staff
Patient and Families
Health Coach
Social Worker/Case Manager
Clinical IT
Nursing Home
Home Care
Hospice
Doctor office/Clinic staff
Dietitian
Tips and Tricks
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VTE patients with documentation that they or their caregivers were given written discharge instructions or other educational material addressing all of the following: follow up monitoring, compliance issues, dietary restrictions, potential for adverse drug reactions/interactions, activity requirements or restrictions
Include discussion of patients on warfarin therapy at your daily huddles
Ensure that patients discharged on warfarin therapy have a scheduled appointment for an INR prior to discharge
Ensure that patients discharged on warfarin therapy have a scheduled medication management consultation within 7 days of discharge
Resources Joint Commission VTE 5 VTE measure information form, click on Specifications Manual for National Hospital Inpatient Quality Measures on fist page and then click on Download Complete Manual v5.1 2. After you download click on the only file showing and find 2d VTE5 AHRQ Watch the Warfarin! Case Study and best practices for the management of warfarin at hospital discharge
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Additional Focus Areas (Optional)
Multi-drug Resistant Organism (MDRO) and Antimicrobial Stewardship
Measures
Outcome Measures: Carbapenem-resistant Enterobacteriaceae (CRE) Prevalence
Numerator: Number of LabID CRE events
Denominator: Number of Acute Care Inpatient days
Data Sources
NHSN
Recommended team members
Quality staff
Infection Preventionist
Providers
Pharmacist
Department Managers/Directors
Frontline staff
Patient and Families
Nursing Home
Home Care
Hospice
Lab
Tips and Tricks
Assemble an interdisciplinary team and develop an aim statement that reflects your organization's Antimicrobial Stewardship goals
Educate and ensure that MDRO education is provided at new employee
orientation and ongoing education throughout the year (Ex. Monthly staff
meetings and competency/skill fairs)
Participate in the HAI community of practice
Ensure your rights are conferred in NHSN to IHC
Resources CDC MDRO and CDI Module NHSN Multi drug resistant organism & clostridium difficile infection Module
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CDCs Carbapenem-resistant Enterobacteriaceae Toolkit
Facility Guidance for Control of CRE
Standardized Antimicrobial Administration Ratio (SAAR) Numerator: Number of observed days of antimicrobial therapy reported by a healthcare facility for a specified category of antimicrobial agents used in a patient care location or group of locations
Denominator: Number of days of antimicrobial therapy predicted for a healthcare facility's use of a specified category of antimicrobial agents in a patient care location or group of locations, calculated by applying negative binomial regression modeling to nationally aggregated AU data
Data Sources
NHSN
Recommended team members
Quality staff
Infection Preventionist
Providers
Pharmacist
Department Managers/Directors
Frontline staff
Patient and Families
Lab
Tips and Tricks
Ensure your rights are conferred in NHSN to IHC
Resources
The Standardized Antimicrobial Administration Ratio (SAAR)
CDC development of SAAR, SAAR output options in NHSN and using the SAAR in Stewardship
Standardized Antimicrobial Administration Ratio (SAAR) Table
CDC SAAR Table
Surveillance for Antimicrobial Use and Antimicrobial Resistance Options
CDC Training, Protocols, Data Collection Forms, Supporting Material and Analysis Resources
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Antimicrobial agent days
Numerator: Number of patient-days when any antimicrobial was prescribed/administered (alone or in combination)
Denominator: Total number of patient days
Data Sources
Self-Reported
Recommended team members
Quality staff
Infection Preventionist
Providers
Pharmacist
Department Managers/Directors
Frontline staff
Patient and Families
Clinical IT
Lab
Resources
CDC Antimicrobial Use and Resistance (AUR) Module Antimicrobial use and resistance requirements and data analyses. Includes antimicrobial groupings for SAAR calculations
Process Measures:
Antibiotic Time Out
Numerator: Number of patients administered antibiotics that have antibiotic "time
out" in order to reassess the continuing need and choice of antibiotics, within 48
hours of initiation of antimicrobial therapy
Denominator: Number of patients prescribed/administered antimicrobial therapy
Data Sources
Self-Reported
Recommended team members
Quality staff
Infection Preventionist
Providers
Pharmacist
Department Managers/Directors
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Frontline staff
Patient and Families
Clinical IT
Lab
Tips and Tricks
Ensure your rights are conferred in NHSN to IHC
Ensure that all antibiotics administered in the hospital include an antibiotic time out
Resources
Core Elements of Hospital Antibiotic Stewardship Programs
CDC – Leadership Commitment, Accountability and Drug Expertise, Policies and Interventions, including Antibiotic “time outs”
Antimicrobial Stewardship
By Keith Hamilton, MD, Associate Hospital Epidemiologist, Director of Antimicrobial Stewardship Hospital of the University of Pennsylvania
National Quality Partners Playbook: Antibiotic Stewardship in Acute Care
Leadership Commitment, Accountability, Drug Expertise, Tracking and Monitoring Antibiotic prescribing, use and resistance
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Hospital Culture of Safety (Worker Safety) Worker safety is about the health and safety of staff members. Hospitals are one of the most hazardous places to work. Patient lifting, repositioning, and transfers represent some of the most common and preventable sources of injury for employees in the healthcare industry. This is new to the IHC HEN. Measures focus on work-related back injuries, needle-safety and ensuring safe patient handling equipment is available for staff. See below for more detailed information about each measure. The outcome measures will help to determine how many and how often staff members are harmed by safety incidents. The process measure will provide hospitals with a checklist to assist with the ensuring safe patient handling equipment is available, accessible and is in working order.
Measures
Outcome Measures: Work-related Back Injuries
Numerator: Number of work-related back injuries
Denominator: Number of FTEs
Data Sources
Self-Reported
Recommended team members
Quality staff
Providers
Department Managers/Directors
Frontline staff
Wound/ostomy staff
Respiratory/Therapy staff
Physical/Occupational/Speech Therapy staff
Lab
Employee Health
Tips and Tricks
Assemble an interdisciplinary team and develop an aim statement that reflects your organization's Worker Safety goals
Educate and ensure that Worker Safety education is provided at new employee
orientation and ongoing education throughout the year (Ex. Monthly staff
meetings and competency/skill fairs)
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Resources
Worker Safety in Hospitals Safe patient handling, understanding the problem Safe Patient Handling- Self-Assessment Busting the Myths Understanding lift equipment Management Support Management, leadership, implementing and assessments Training and Education Training, lift equipment, patient and family, champions and assessments Knowing the Facts Learn from the Leaders Case Studies
Policy and Program Support How to start a policy and a program Program Evaluation Case Studies Effectiveness and Cost Savings Examples, University of Iowa
Needlesticks Numerator: Number of needlestick events
Denominator: Number of FTEs
Data Sources
Self-Reported
Recommended team members
Quality staff
Infection Preventionist
Providers
Pharmacist
Department Managers/Directors
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Frontline staff
Wound/ostomy staff
Lab
Employee Health
Tips and Tricks
Assemble an interdisciplinary team and develop an aim statement that reflects your organization's Worker Safety goals
Educate and ensure that Worker Safety education is provided at new employee orientation and ongoing education throughout the year (Ex. Monthly staff meetings and competency/skill fairs)
Resources
Sharps Safety for Healthcare Settings This safety workbook from The Centers for Disease Control and Prevention (CDC) can help to create or improve an injury prevention program to reduce occupational exposure to bloodborne pathogens
Stop Sticks Campaign The CDC and The National Institute for Occupational Safety and Health (NIOSH) provide information on how to stop sharps injuries. This campaign focuses on empowering healthcare providers and workers to be safe when working around sharps
Workbook for Designing, Implementing, and Evaluating a Sharps Injury Prevention Program This workbook details how to create, improve, and/or evaluate new or current needlestick injury prevention programs
Process Measure: Safe Patient Handling Program Equipment Checklist Compliance
Numerator: Number of units with all checklist items ‘In Place’
Denominator: Number of units assessed
Data Sources
Self-Reported
Recommended team members
Quality staff
Providers
Department Managers/Directors
Frontline staff
Patient and Families
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Wound/ostomy staff
Respiratory/Therapy staff
Physical/Occupational/Speech Therapy staff
Tips and Tricks
Utilize the checklist provided
Begin with one unit and add units to show improvement
Resources
Safe Patient Handling Program Checklist
Training and Education By educating all staff, including providers, about your safe patient handling program, hospitals can reduce instances of a clinician asking or expecting colleagues to move patients in an unsafe way
Management Support One of the most important aspects of any safe patient handling program is support from the top levels of hospital administration. This resource will provide information to help start these conversations Policy and Program Support Safe patient handling policies establish expectations that staff will use the safest techniques to accomplish patient handling tasks, and that administrators will provide equipment and resources to support staff efforts
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Undue Exposure to Radiation Undue exposure to radiation is avoiding unnecessary testing to reduce exposure to radiation. The measures focus on abdomen CT and thorax CT. See below for more detailed information about each measure. These measures will help to determine how many and how often patients are exposed to undue radiation.
Measures
Outcome Measures: Abdomen CT – Use of Contrast Material (CMS)
Numerator: Number of abdomen CT studies with and without contrast ('combined studies')
Denominator: Number of abdomen CT studies performed (with contrast, without contrast OR both with and without contrast)
Data Sources
IPOP/Claims Data (where available)
Self-Reported
Recommended team members
Quality staff
Providers
Department Managers/Directors
Frontline staff
Patient and Families
HIM
Radiologist
Tips and Tricks
Assemble an interdisciplinary team and develop an aim statement that reflects your organization's Radiation Safety goals
Educate and ensure that Undue Exposure to Radiation Safety education is
provided at new employee orientation and ongoing education throughout the year
(Ex. Monthly staff meetings and competency/skill fairs)
Educate patients and families about radiation safety
Resources
HRET Top Ten Checklist for Radiation Safety
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Radiological Society of North America (RSNA) “How I Do It: Managing Radiation Dose in CT” Mayo-Smith, W. W., Hara, A. K., Mahesh, M., Sahani, D. V., & Pavlicek, W. (2014) Radiology Today Choosing Wisely, Imaging Procedures on the Latest List of Ones ‘Patients and providers should question’
Thorax CT – Use of Contrast Material (CMS) Numerator: Number of thorax CT studies with and without contrast ('combined studies') Denominator: Number of abdomen CT studies performed (with contrast, without contrast OR both with and without contrast)
Data Sources
IPOP/Claims data (where available)
Self-reported
Recommended team members
Quality staff
Providers
Department Managers/Directors
Frontline staff
Patient and Families
HIM
Radiologist
Tips and Tricks
Educate patients and families using posters and infographics with helpful information about radiation exposure
Ensure that patients have been evaluated for elevated blood d-Dimer levels and certain specific risk factors before imaging suspected pulmonary embolisms
Educate patients and families about radiation safety
Resources
HRET Top Ten Checklist for Radiation Safety Radiological Society of North America (RSNA) “How I Do It: Managing Radiation Dose in CT” Mayo-Smith, W. W., Hara, A. K., Mahesh, M., Sahani, D. V., & Pavlicek, W. (2014)
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Radiology Today Choosing Wisely, Imaging Procedures on the Latest List of Ones ‘Patients and providers should question’
Process Measures: Total CT Dose Capture Compliance –Dose Length Product (DLP)
Numerator: Total number of CTs in which the total DLP is recorded
Denominator: Total number of CTs
Data Sources
Self-Reported Recommended team members
Quality staff
Providers
Department Managers/Directors
Frontline staff
Clinical IT
Radiologist
Resources
Radiological Society of North America (RSNA) “How I Do It: Managing Radiation Dose in CT” Mayo-Smith, W. W., Hara, A. K., Mahesh, M., Sahani, D. V., & Pavlicek, W. (2014) Radiology Today Choosing Wisely, Imaging Procedures on the Latest List of Ones ‘Patients and providers should question’
Total CT Dose Capture Compliance – Volume CT Dose Index (CTDIvol) Numerator: Total number of CTs in which the total CTDIvol is recorded
Denominator: Total number of CTs
Data Sources
Self-Reported
Recommended team members
Quality staff
Providers
Department Managers/Directors
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Frontline staff
Clinical IT
Radiologist
Resources
Radiological Society of North America (RSNA) “How I Do It: Managing Radiation Dose in CT” Mayo-Smith, W. W., Hara, A. K., Mahesh, M., Sahani, D. V., & Pavlicek, W. (2014) Radiology Today Choosing Wisely, Imaging Procedures on the Latest List of Ones ‘Patients and providers should question’ Total CT Dose Capture Compliance – Size-specific Dose Estimate (SSDE)
Numerator: Total number of CTs in which the total SSDE is recorded
Denominator: Total number of CTs
Data Sources
Self-Reported
Recommended team members
Quality staff
Providers
Department Managers/Directors
Frontline staff
Clinical IT
Radiologist
Resources
Radiological Society of North America (RSNA) “How I Do It: Managing Radiation Dose in CT” Mayo-Smith, W. W., Hara, A. K., Mahesh, M., Sahani, D. V., & Pavlicek, W. (2014) Radiology Today Choosing Wisely, Imaging Procedures on the Latest List of Ones ‘Patients and providers should question’
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Obstetrical Adverse Events Obstetrical adverse events affect mothers and their infants. The events range from perineal tears to maternal or infant death, leading to extensive hospital admissions and/or neonatal intensive care. All pregnant women and their infants are at risk during labor and delivery. These measures focus on the number of early elective deliveries, uncomplicated primary cesarean delivery rates, peripartum hysterectomy (with and without placenta previa), birth trauma rates, OB trauma (with and without instrument), timely treatment for hypertension, and risk assessment for maternal hemorrhage. See below for more detailed information about each measure.
These measures help to determine how many and how often women are harmed by obstetrical adverse events.
Measures
Outcome Measures: Early Elective Delivery
Numerator: Number of elective maternal deliveries between 37-39 weeks gestation with no medical indication
Denominator: All deliveries between 37-39 weeks gestation
Data Sources
Self-Reported Recommended team members
Quality staff
Providers
Department Managers/Directors
Frontline staff
Patient and Families
Health Coach
Social Worker/Case Manager
Doctor office/Clinic staff
Tips and Tricks
Assemble an interdisciplinary team and develop an aim statement that reflects your organization's Obstetrical goals
Educate and ensure that Obstetrics education is provided at new employee
orientation and ongoing education throughout the year (Ex. Monthly staff
meetings and competency/skill fairs)
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Hard stop policy in place for EED prior to 39 weeks gestation
Provide education to patients and families
Resources
HRET Top Ten Checklist for OB Harm Top ten evidence based interventions The Joint Commission Joint Commission Performance Measurement FAQs (Click on Performance Measurement FAQs) National Archives and Records Administration – Office of the Federal Register Federal Register, Vol. 77, No. 170/Friday, August 31, 2012/Rules and Regulations. Look to the second column, Page 53528, under (C) “New Chart-abstracted measures: Elective Delivery…” Institute for Healthcare Improvement How-to-Guide: Prevent Obstetrical Adverse Events. Essential elements of prevention, oxytocin bundles, design strategy, forming the team, PDSA worksheet and measurement CDC: Pregnancy Mortality Surveillance System Trends in Pregnancy-Related Deaths
Primary Cesarean Delivery Rate, Uncomplicated
Numerator: Number of maternal inpatients with either MS-DRG code for Cesarean delivery or any-listed ICD-9/10 procedure code(s) for Cesarean delivery without any-listed ICD-9/10 procedure code(s) for hysterectomy
Denominator: Number of deliveries
Data Sources
IPOP/Claims Data (where available)
Self-Reported
Recommended team members
Quality staff
Providers
Department Managers/Directors
Frontline staff
Patient and Families
Health Coach
Social Worker/Case Manager
HIM
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Doctor office/Clinic staff
Tips and Tricks
Denominator has specifications: deliveries without previous Cesarean section, abnormal presentation (breech), fetal death or multiple gestation (see technical specifications in AHRQ IQI 33 description)
Review the culture at your hospital, is primary C-section being actively prevented
Be aware of the percentages of Early Elective Inductions that turn in C-sections
Be aware of provider specific commonalitie
Resources
HRET Top Ten Checklist for OB Harm Top ten evidence based interventions Primary Cesarean Delivery Rate, Uncomplicated Technical Specifications – Inpatient Quality Indicators #33 The Joint Commission Joint Commission Performance Measurement FAQs (Click on Performance Measurement FAQs) Institute for Healthcare Improvement How-to-Guide: Prevent Obstetrical Adverse Events. Essential elements of prevention, oxytocin bundles, design strategy, forming the team, PDSA worksheet and measurement CDC: Pregnancy Mortality Surveillance System Trends in Pregnancy-Related Deaths
Birth Trauma Rate – Injury to Newborn (ARHQ PSI 18) Numerator: Number of Newborns with ICD-9/ICD-10 code(s) for birth trauma
Denominator: Number of Newborns
Data Sources
IPOP/Claims Data (where available)
Self-Reported
Recommended team members
Quality staff
Providers
Department Managers/Directors
Frontline staff
Patient and Families
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HIM
Doctor office/Clinic staff
Tips and Tricks
Denominator excludes preterm infants with birth weight less than 2000 grams, injury to brachial plexus or osteogenesis imperfecta
Delegate the responsibility to review all cases where neonatal injury is present
Be aware of commonalities with types of procedure or provider that result in birth trauma
Be aware of coding errors, are your coders familiar with normal and abnormal findings
Resources
HRET Top Ten Checklist for OB Harm Top ten evidence based interventions Birth Trauma Rate – Injury to Neonate Technical Specifications, Patient Safety Indicators #17 ICD 9/ICD 10 The Joint Commission Joint Commission Performance Measurement FAQs (Click on Performance Measurement FAQs)
Obstetrical Trauma Rate – Vaginal Delivery with Instrument
Numerator: Number of vaginally-delivering, instrument-assisted Moms with ICD9/10 code(s) for 3rd or 4th degree obstetric trauma
Denominator: Number of vaginal deliveries with ICD-9/10 procedure code(s) for instrument-assisted delivery
Data Sources
IPOP/Claims Data (where available)
Self-Reported Recommended team members
Quality staff
Providers
Department Managers/Directors
Frontline staff
Patient and Families
HIM
Doctor office/Clinic staff
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Tips and Tricks
Denominator excludes preterm infants with birth weight less than 2000 grams, injury to brachial plexus or osteogenesis imperfecta
Include your coders
Resources
HRET Top Ten Checklist for OB Harm Top ten evidence based interventions
Obstetric Trauma Rate – Vaginal Delivery With Instrument Technical Specifications, Patient Safety Indicators #18 ICD 9/ICD 10
The Joint Commission Joint Commission Performance Measurement FAQs (Click on Performance Measurement FAQs) Institute for Healthcare Improvement How-to-Guide: Prevent Obstetrical Adverse Events. Essential elements of prevention, oxytocin bundles, design strategy, forming the team, PDSA worksheet and measurement CDC: Pregnancy Mortality Surveillance System Trends in Pregnancy-Related Deaths
Obstetrical Trauma Rate – Vaginal Delivery Without Instrument (ARHQ PSI 19) Numerator: Number of vaginally-delivering, non instrument-assisted Moms with ICD9/10 code(s) for 3rd or 4th degree obstetric trauma
Denominator: Number of vaginal deliveries with ICD-9/10 procedure code(s) for non-instrument-assisted delivery
Data Sources
IPOP/Claims Data (where available)
Self-Reported
Recommended team members
Quality staff
Providers
Department Managers/Directors
Frontline staff
Patient and Families
HIM
Doctor office/Clinic staff
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Tips and Tricks
Denominator excludes preterm infants with birth weight less than 2000 grams, injury to brachial plexus or osteogenesis imperfecta
Include your coders
Resources
HRET Top Ten Checklist for OB Harm Top ten evidence based interventions Obstetric Trauma Rate – Vaginal Delivery Without Instrument Technical Specifications, Patient Safety Indicators #19 ICD 9/ICD 10 The Joint Commission Joint Commission Performance Measurement FAQs (Click on Performance Measurement FAQs) Institute for Healthcare Improvement How-to-Guide: Prevent Obstetrical Adverse Events. Essential elements of prevention, oxytocin bundles, design strategy, forming the team, PDSA worksheet and measurement CDC: Pregnancy Mortality Surveillance System Trends in Pregnancy-Related Deaths
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ED Transfer Communication (MBQIP, for applicable facilities) Compliance for each category means all components have documentation in the ED record. Report up to 45 or less (no more) per quarter to meet Rural Emergency Department Transfer Communication measure. To meet HRSA/Flex requirements for MBQIP, report monthly data by expected timeline that is specified on pg. 7 of this document.
ED Transfer Communication Numerator: Number of ED patients transferred to another healthcare facility where all elements were communicated to the receiving facility
Denominator: Number of ED patients transferred to another healthcare facility (Hospice Healthcare Facility, Acute Care Facility (CAH/General Inpatient Care/Cancer/Children's/VA)
Data Sources
Self-Reported Recommended team members
Quality staff
Providers
Pharmacist
Department Managers/Directors
Frontline staff
Health Coach
Social Worker/Case Manager
Clinical IT
Nursing Home
Home Care
Hospice
Lab
Doctor office/Clinic staff
Tips and Tricks
To meet HRSA/Flex requirements for MBQIP, report monthly data by expected timeline that is specified on pg 7 of this document
Compliance for each category means all components have documentation in the ED record. Report up to 45 or less (no more) per quarter to meet Rural Emergency Department Transfer Communication measure
Remember that the “All” category must not be higher than the lowest category
Please direct all questions on MBQIP measures to your Telligen Improvement Advisor, Lori Parsons, email lparsons@telligen.com
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Resources QIO Stratis Health Rural EC Transfer Communication Resources
Data specifications manual, action plan, checklists and data collection tool
For the following breakouts, report numerator information matching each area for same
denominator as defined above
I. Administrative Communication
Numerator: Number of ED patients transferred to another healthcare facility
whose medical record documents indicate that all Patient Information (name,
address, age, gender, significant other contact information and insurance
information) was communicated
Data Source:
Self-Reported
II. Patient Information
Numerator: Number of ED patients transferred to another healthcare facility
whose medical record documents indicate that all Administrative Communication
(nurse-to-nurse communication and physician-to-physician communication) was
communicated
Data Source:
Self-Reported
III. Patient Information
Numerator: Number of ED patients transferred to another healthcare facility
whose medical record documents indicate that all Vital Signs (pulse, respiratory
rate, blood pressure, oxygen saturation, temperature and Glasgow Coma
Scale/neuro assessment) were communicated
Data Source:
Self-Reported
IV. Patient Information
Numerator: Number of ED patients transferred to another healthcare facility
whose medical record documents indicate that all Medication Information
(medications administered in ED, allergies and home medications) was
communicated
Data Source:
Self-Reported
V. Patient Information
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Numerator: Number of ED patients transferred to another healthcare facility
whose medical record documents indicate that all Practitioner-Generated
Information (history and physical, reason for transfer and plan of care) was
communicated
Data Source:
Self-Reported
VI. Patient Information
Numerator: Number of ED patients transferred to another healthcare facility
whose medical record documents indicate that all Nurse-Generated Information
(nursing assessments/interventions/response, sensory status, catheters,
immobilizations, respiratory support and oral limitations) was communicated
Data Source:
Self-Reported
VII. Patient Information
Numerator: Number of ED patients transferred to another healthcare facility
whose medical record documents indicate that all Tests and Procedures done
and Tests and Procedure Results Sent were communicated
Data Source
Self-Reported
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