Facility Informational Webinar Cohort 5 2015 Health Research & Educational Trust Project Team Members

Agenda Topic Presenter Welcome and Project Overview Marcia Cooke Achieving Project Goals Louella Hung Measuring Success A.J. Rolle LTC Facility Team Lead Role Lindsay Kolczynski Timeline & Next Steps Helen Plass Question & Answer All Attendees and Presenters

Project Overview Marcia Cooke, DNP, RN-BC Director, Clinical Quality at HRET Project Overview

Objectives Recognize project goals and why the project matters Identify the approach to education, coaching and measuring progress Summarize Facility and Facility Team Lead responsibilities Describe how HRET and the National Project Team will support facilities Recall upcoming key dates

State or Regional Lead Organizations, Multi-Facility Operators Partnerships & Dissemination AHRQ Safety Program for Long-term Care: HAIs/CAUTI AHRQ National Project Team HRET UM Abt Qualidigm APIC SHM Baylor State or Regional Lead Organizations, Multi-Facility Operators Faculty Organizational Leads Recruitment National & Regional Faculty UM, Abt, Qualidigm, APIC, SHM, Baylor Coaching/Endorsement Facilities HRET Program Manager Monitoring and Support

Connections for the Facility Team HRET Program Managers Organizational Lead Facilities HRET Faculty Coach Facility Teams Helen Plass, MA hplass@aha.org 312.422.2659 Janine Reisinger, MPH jreisinger@aha.org 312.422.3111 Amanda Wilkins, MPA awilkins@aha.org 312.422.2717

Causes of Re-hospitalizations From LTCFs Top reasons for re-admission from LTC facility to a community hospital: CHF 31% UTI 28% Renal Failure 27% Pneumonia 23% COPD 23% Source: Ouslander JG. Journal of the American Medical Directors Association, March 2011. “CHF, respiratory infection, UTI, sepsis, and electrolyte imbalance account for 78% of 30 day rehospitalizations from SNFs” Source: Unpublished MedPAC data cited by Mor V. Health Affairs, January 2010

Why This Project Matters 1-3 million serious infections annually in LTC facilities Approximately 380,000 residents die of infections each year UTIs are one of the most common HAls in LTC facilities Infections are among the most frequent causes of transfer and re-admissions from LTC facilities to acute care hospitals High prevalence of urinary catheters in hospital patients transferred to LTC facilities Improving safety and quality of life for residents and their families is our overall aim!

What’s in it for LTC Facilities? Improve care and resident/family satisfaction Align with CMS 11th SOW/QAPI and Advancing Excellence Strengthen all staff members’ infection prevention knowledge and skills, using evidence-based content and training materials Earn CNE credits Avoid penalties for violations of F 315 and F 441 Reduce staff workload burden Maintain higher census from lower mortality, hospitalization Prepare for value-based purchasing

How Will LTC Facilities Benefit From Participation Potential to: Improve the Nursing Home Compare Quality Measures Enhance data collection skills and prepare for mandatory reporting of infection data (NHSN) Benchmark against other LTC facilities (project-level and nationally) Improve communication and relationships with referring hospitals that may results in reduced readmissions Improve compliance with survey requirements related to quality of care, infection control, etc.

Project Goals Primary Goals—reduce HAIs/CAUTI and improve safety culture Develop/adapt evidence-based CAUTI elimination and safety practices and resources for LTCFs Reduce CAUTIs and HAIs Improve safety culture Secondary Goals—support expanded infection prevention efforts for C. diff, UTI, MDROs, etc. by providing education to: Improve hygiene practices (hand, environmental) Promote antibiotic stewardship Promote catheter stewardship Reduce re-hospitalizations

Project Spread 539 Facilities Actively Participated in Cohorts 1-4 Aim to involve all 50 states, D.C. and Puerto Rico Cohort 1 (63 facilities) Cohort 2 (142 facilities) Cohort 3 (215 facilities) Cohort 4 (119 facilities and counting!) PR

Achieving Project Goals Louella Hung, MPH Senior Program Manager at HRET Achieving Project Goals

How will These Goals be Achieved? Clinical Interventions Cultural Interventions Evidence-based infection prevention practices Indwelling catheter, UA/culture and antibiotic stewardship Strategies to avoid re- hospitalizations, catheter alternatives Learning from defects to understand and prevent adverse events Senior leadership engagement Front-line staff empowerment Teamwork and communication Regular team meetings

Educational Sessions Virtual learning sessions: kickoff and final Slides, expert faculty, interactive activities, handouts, resources Educational webinar/video series Name of series # of Topics Frequency What Format for Facility Team Lead Format for Front-line Staff Onboarding 4 Weekly Project orientation Webinar Trained by Facility Team Lead Training Modules 2 modules every 3 weeks Infection prevention Videos Videos, and trained by Facility Team Lead Safety Culture Survey Results Forum 1 Once Safety culture N/A Content 7 Monthly Clinical and cultural interventions

Support for Education Components Train-the-Trainer Guide Core Team Training Materials Webinar Recording Core Team Presentation Slides (Chat Summary and Q&A) Supplemental Materials All Staff Training Materials Video and Facilitator Slides Discussion Guide/Activity Event Evaluation Template Certification of Completion Template Additional Resources

Education Series Schedule Virtual Learning Session Date Time Learning Session 1a Thursday, September 10 11:30 a.m. – 1:30 p.m. CT Learning Session 1b Thursday, September 24 11:00 a.m. – 1:00 p.m. CT Onboarding Webinar Series 1. Building a Culture of Safety Team Thursday, October 1 1:00 – 2:00 p.m. CT 2. CAUTI Definitions Thursday, October 8 3. Data Collection Training Thursday, October 15 4. CAUTI Surveillance Thursday, October 22 Training Module Series Release Date 1. Hand Hygiene November 16 N/A 2. Environment & Equipment 3. Isolation Precautions December 7 4. Antibiotic Stewardship Monthly Webinar Series National Content 3rd Thursday of each month, beginning in January 11:15 a.m. – 12:15 p.m. CT

Coaching Calls When: Monthly, beginning in November Who: All facility team leads HRET Program Managers facilitate and provide project management support and technical assistance Faculty coach provides clinical, cultural and surveillance expertise Why: Review data and track project progress Discuss educational webinars and project interventions Share successes, challenges and best practices with other facilities Ask Faculty Coach and facility teams to engage in use of project tools, resources How: Web conference

Your HRET Program Manager LTC Safety Website Resources Your HRET Program Manager LTC Safety Website username & password: ltcsafety Weekly Newsletters Expert Faculty Coaches Facility Implementation Guide Data Support

AJ Rolle, MPH Program Manager at HRET Measuring Progress

Purpose of Measurement Measures are developed to support hard-wiring of resident safety processes with attention to the needs of the LTC environment. Improving safety and quality of life for residents and their families is our overall aim!

Required Data Metrics and Schedule Data Collected Frequency Time to Complete Background/Cultural Measures -> Drive Change Registration 1x to enroll 10 minutes Facility Demographics 1x at enrollment 15 minutes Safety Culture Survey 2x (Month 3 and 10) Process Measures -> Evidence-based practice Knowledge Questionnaire 2x (Month 1 and 8) Outcome Measures –> Understand and celebrate success Catheter Utilization CAUTI rates Urine culture order rates Monthly

Outcome Data Definitions

Data Collection Systems Cvent Comprehensive Data System (web-based survey portal) Registration Facility Demographics Skills Questionnaire Safety Culture Survey Event evaluations (HRET’s online data portal) Outcome Measures* Residents Residents with catheters New CAUTI events Urine culture orders * CDC’s National Healthcare Safety Network (NHSN) can also be used to enter some of the outcome measures. Facilities must confer rights to HRET (contact HRET program manager for additional information).

Measurement Support Checklist tools to support awareness and adherence to evidence-based recommendations NHSN CAUTI definition assessment worksheet NHSN CAUTI definition pocket cards Data collection tools Data submission reports Results distributed within 4-6 weeks after submission deadlines

Facility Team Lead Role Lindsay Kolczynski, MBA Senior Program Manager at HRET Facility Team Lead Role

How We Will Support You Your Lead Organization will… Answer any questions you have about the program prior to registration Guide you through the enrollment process Your HRET Program Manager will… Send newsletters with data submission rates, project due dates, content information, project milestones and tips for success Provide you with an implementation manual during Learning Session 1 Have subject matter experts available outside of content webinars Troubleshoot any data and program implementation issues Follow-up with you throughout the project to check on your progress and connect you with resources

Facility Team Expectations Time Commitment: 5% FTE or 80-90 hours during the 11 month program Promote the project goals Learn and implement the clinical and cultural improvement tools Participate in monthly team safety huddles to review outcome, process, and teamwork and communication data Attend virtual learning sessions Comply with data collection and submission requirements, including the completion of the AHRQ Nursing Home Survey on Patient Safety Culture, at the beginning of the program Attend monthly coaching and content calls

Facility Team Lead Expectations Track facility progress and meet data requirements Submit process and outcome data Safety culture survey at baseline Meet regularly with LTC facility team to monitor progress Hold safety meetings with the team, monthly Ask for help on behalf of the team Call your HRET Program Manager to discuss team and program challenges, monthly

Helen Plass, MA Program Manager at HRET Timeline & Next Steps

Cohort 5 Timeline

Onboarding Educational Series September 2015 Sunday Monday Tuesday Wednesday Thursday Friday Saturday   1 2 3 4 5 6 7 Labor Day 8 9 10 Virtual Learning Session 1a 11:30 a.m.-1:30 p.m. CT 11 12 13 14 15 16 17 18 DUE: Facility Registration 19 20 21 22 23 24 Virtual Learning Session 1b 25 26 27 28 29 30 DUE: Facility Demographics DUE: Baseline Knowledge Questionnaire Onboarding Educational Series 3rd Thursday of each week in October from 1-2 p.m. CT

Questions about Enrollment? State Organizational Lead Contact Person Email AZ Arizona Health and Hospital Association Sandy Severson sseverson@azhha.org OR Oregon Patient Safety Commission Mary Post mary.post@oregonpatientsafety.org RI Healthcentric Advisors Pam Quinn pquinn@healthcentricadvisors.org MI, MA, FL HRET Lindsay Kolczynski lkolczynski@aha.org ND Quality Health Associates of North Dakota Michelle Alauckner mlauckner@qualityhealthnd.org SC South Carolina Hospital Association Diana Zona dzona@scha.org So FL South Florida Hospital and Healthcare Association Linda Quick lquick@sfhha.com TN Tennessee Health Care Association Linda Estes lestes@thca.org UT HealthInsight Linda Egbert legbert@healthinsight.org Questions about Enrollment?

Your Feedback is Important Please complete the evaluation for today’s event. Evaluate Event Now