QSource Update: Reducing Hospital Infections Manoj Jain, MD, MPH Medical Director, QSource 11 March, Memphis 17 March, Knoxville 26 March, Nashville

Objectives for Today: Vision/Mission Major Initiatives in TN by QIO and TN Center for Patient Safety (TCPS) on MRSA/SCIP QSource/TCPS MRSA/SCIP Crosswalk Model for Change Within the MDRO Module Other Present and Future Initiatives Preparing for the Future

The right care for every person, every time. CMS Vision Statement for the National Healthcare Quality Improvement Program

S afe T imely E ffective Efficient Equitable P atient-centered The Institute of Medicine The Right Care

History Recruitment Measures Intervention Evaluation MRSA and SCIP – QSource and TCPS Two Parallel, Overlapping, and Synergistic Initiatives

Historical Perspectives: Aug 2008 thru July 2011 – 3 year timeframe Funding from CMS through QIOs Clinical Advisors - Manoj Jain, MD, MPH; Marion Kainer, MD Team Leaders – QSource Patient Safety Team Jan 2008 thru Jan 2010 – 2 year timeframe Funding from TN BC-BS Health Foundation thru THA TCPS Clinical Advisors – Peter Pronovost, MD & Chris Goeschel; Marion Kainer, MD Team Leader - V/P and Director TCPS

Recruitment Outcomes: MRSA 30 Hospitals SCIP 22 Hospitals MRSA 63 Hospitals SCIP 69 Hospitals

SCIP Measure Comparisons: SCIP Inf-1 Antibiotic Administration within One Hour Before Incision SCIP Inf-2 Use of Antimicrobial Recommended in Guideline SCIP Inf-3 Antibiotic Discontinuation within 24 Hours of Surgery End SCIP Inf-4 Glucose Control in Cardiac Surgery Patients SCIP Inf-6 Appropriate Hair Removal SCIP-VTE-1 Recommended VTE Prophylaxis Ordered SCIP-VTE-2 Received Appropriate VTE Prophylaxis within 24 Hours After Surgery SCIP Inf-1 Antibiotic Administration within One Hour Before Incision SCIP Inf-2 Use of Antimicrobial Recommended in Guideline SCIP Inf-3 Antibiotic Discontinuation within 24 Hours of Surgery End SCIP Inf-4 Glucose Control in Cardiac Surgery Patients SCIP Inf-6 Appropriate Hair Removal SCIP Inf-7 Normothermia SCIP-VTE-1 Recommended VTE Prophylaxis Ordered SCIP-VTE-2 Received Appropriate VTE Prophylaxis within 24 Hours After Surgery

MRSA Measure Comparisons: MRSA-1 MRSA Infection Rate – MRSA healthcare-associated infections that are not present or incubating on admission to the identified unit MRSA-2 Hospital Onset MRSA Incidence Rate Based on Clinical Cultures – a proxy measure of MRSA infections based on clinical cultures that have a hospital-onset Required: # of Admissions to Specific Unit During Reporting Period or Facility Wide # of Patient Days in Specific Unit During Reporting Period or Facility Wide Hospital Onset MRSA (all cultures) Optional Measures Also Reportable (See Crosswalk)

MRSA/SCIP Intervention Similarities: Intensive Approach Onsite visits Assistance with AHRQ Survey Teach TeamSTEPPS Methodology Conference Calls Webinars Broader Approach Regional Workshops Statewide Meetings Monthly Conference Calls Assistance with AHRQ Survey Webinars

MRSA/SCIP Parallel Reporting Techniques: SCIP – monthly through TCPS Website MRSA – monthly through MDRO Module SCIP – monthly through TCPS Website MRSA – monthly through TCPS Website

MRSA/SCIP Evaluation and Feedback Comparisons: Monthly data feedback with comparisons/ benchmarks Monitor closely and intervene as needed Monthly data feedback with comparisons/ benchmarks Provide assistance as requested

Summary of Parallel Initiatives: Collecting Many of the Same Measures AHRQ Survey Monthly Reporting of Measures Conference Calls with Clinical Advisors Monthly Feedback of Data with Benchmarking Data/Comparison to Other Collaborators

Health Research and Educational Trust (HRET) Effort to Replicate Successes of Michigan Keystone Project Nationally Conducting in Conjunction with American Hospital Association (AHA) Comprehensive Unit-Based Safety Program (CUSP) – Can Be Focused on Any Topic To Pilot Soon in 10 States Through QIOs and State Hospital Associations TN is Ahead of the Game Thanks to THA/TCPS!

MDRO Module – Present CDC/CMS Model for Change

Key Elements of MDRO Module Use of Module to Monitor at Least One Inpatient Unit with High MRSA Rates Enables Hospitals to Conduct MRSA Infection Surveillance and Lab-ID Event Reporting Enables Hospitals to Collect Data on Process Measures (Hand Washing, Barrier Precautions, etc.) Hospitals Can Also Choose to Collect Data on CDAD

When MDRO Module goes Live: Statewide QSource Trainings in Collaboration with Dr. Marion Kainer on the Electronic Tool/Module Tentatively Scheduled for April 2009 To be Held in 3 Cities Across the State CMS Baseline Timeframe Began 2/1/09 Monthly Data Entry Expectation

Other QSource and TCPS Initiatives: QSource: Crossing the Continuum – NH and Hospital Pressure Ulcer Project Drug Safety – Looking at Potentially Inappropriate Medications and Drug-to- Drug Interactions in Part D Data TCPS: Central Line Blood Stream Infections (CLBSI)

Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU): March 12th THA/QSource Webinar on the Release of the Dry Run Version of Hospital Specific Reports on AHRQ Measures Latest HQA Preview Report for Discharge Quarters Q3 07 through Q2 08 – Withholding Period Ended 2/17/09; to go Live on Hospital Compare March 2009

Next QSource Statewide Abstraction Clinic: March 19, 2009 from 9:00-10:30 CST To Highlight Changes to Q2/Q Specifications Manual and Abstraction Guidelines

Why Do Some Hospitals Succeed? JAMA May 23/30, 2001 vol285, No 20 Shared Goals for Improvement Substantial Administrative Support Strong Physician Leadership Credible Data Feedback

5 Strategies to Stay Off The List! Prepare – Know Your Numbers Have a Team to Deploy/Assist with Efforts Learn and Teach QI to All – IP/Nurse Manager/ Front Line Staff Make a Business Case for Infection Prevention Get Leadership Engaged and Boards on Board

What QI/IP Staff Need to Be Doing NOW You are the Change Agent and Knowledge Base for Quality Improvement and Infection Prevention in Your Institution. –Culture Change/Work Together –Institute Concurrent Care Management –Standardize Infection Processes (Use Opt Out Approach for Order Sets) –Conduct Informal RCA of Cases that Fall Out –Engage Physicians –ASK Frontline Staff and Feedback Data Regularly

The right care for every person, every time. CMS Vision Statement for the National Healthcare Quality Improvement Program

Manoj Jain, MD, MPH Medical Director, QSource Thank You! This presentation and related materials were developed by QSource, the Medicare Quality Improvement Organization for Tennessee, under contract with the Centers for Medicare & Medicaid Services (CMS), a division of the Department of Health and Human Services. Contents do not necessarily reflect CMS policy. QSOURCE-TN QSource Update: Reducing Hospital Infections