1. Tennessee Center for Patient Safety Data Reporting

2. Scope of TCPS Data Collection Methicillin-resistant Staphylococcus aureus (MRSA) Central Line Associated Blood Stream Infections Surgical Care Improvement Project (SCIP) data from core measures AHRQ Hospital Survey on Patient Safety Culture

3. MRSA Data Reporting Reported monthly by hospitals participating in the MRSA collaborative via THA web site Data collection initiated August 2008 Data included for units that reported complete data for January – August 2008 –Baseline is defined as January - June

4. Definitions for MRSA based on CDC MDRO Module NHSN Definitions MRSA includes S. aureus cultured from any specimen that tests oxacillin (or cefoxitin for oxacillin) resistant by standard susceptibility testing methods, or by a positive result from molecular testing for mecA and PBP2a; these methods may also include positive results of specimens tested by any other FDA approved PCR test for MRSA. Healthcare Facility-onset (HO) Incident: LabID Event > 3 days after admission (i.e. on or after day 4). Community-onset (CO): LabID Event collected as an outpatient or an inpatient ≤ 3 days after admission (i.e. day 1, day 2 or day 3 of admission). These data do not include results from active surveillance tests.

5. Number of Admissions, Patient Days and Cases of Hospital Onset MRSA in Tennessee Hospitals Reporting Facility Wide MRSA Data by Month of Occurrence, 2008 Includes 24 hospitals that reported data for every month

6. Number of Admissions, Patient Days and Cases of Hospital Onset MRSA in Tennessee Hospitals Reporting Inpatient Adult Critical Care Unit MRSA Data by Month of Occurrence, 2008 Includes 5 hospitals that reported unit data for every month

7. Number of Admissions, Patient Days and Cases of Hospital Onset MRSA in Tennessee Hospitals Reporting Inpatient Adult Unit MRSA Data by Month of Occurrence, 2008 Includes 4 hospitals that reported unit data for every month

9. Number of Admissions, Patient Days and Cases of Community Onset MRSA in Tennessee Hospitals Reporting Facility Wide MRSA Data by Month of Occurrence, 2008 Includes 16 hospitals that reported data for every month

13. Central Line Associated Bloodstream Infections Definition of CLABSIs to be reported based on CDC NHSN –Reportable primary bloodstream infections are either laboratory confirmed bloodstream infections (LBCI) or in the case of neonates (30 days old or younger) and infants (1year old and younger) clinical sepsis (CSEP). Central line is an intravascular catheter that terminates at or close to the heart or in one of the great vessels which is used for infusion, withdrawal of blood, or hemodynamic monitoring. The following are considered great vessels for the purpose of reporting central line infections and counting central line days (as defined for the NHSN system): –Aorta, pulmonary artery, superior vena cava, inferior vena cava, –Brachiocephalic veins, interjugular veins, subclavian veins, –External iliac veins, common femoral veins

14. Central Line Associated Bloodstream Infections  Patient Safety Center reporting options  Data reported directly to THA via web reporting tool  Hospital requested data be submitted to THA from CDC NHSN data by the Department of Health  CDC NHSN reporting requirement for Tennessee  T.C.A. 68-11-263: Facilities must join the CDC National Healthcare Safety Network (NHSN) to report central line bloodstream infections in ICU’s  Excludes facilities with average daily census of 25 or less  Excludes burn units and level 1 trauma units  Hospitals began submission of required data January 2008

15. Central Line Associated Bloodstream Infections Data collection initiated August 2008 Data included for units that reported complete data for January – August 2008 Baseline defined as January - June Initial data from State received in mid October 31 hospitals reported data for 74 units since August 24 hospitals reported complete data for 47 units for January through August, 2008 Of the 47 units with complete data, 18 reported 0 infections during the entire 8 month period

16. Number of Central Line Bloodstream Infections in Tennessee Hospitals Reporting Adult Medical/Surgical Critical Care Unit Infections Every Month, January – August, 2008 The 2007 national incidence rate for all hospitals reporting CLABSIs for medical/surgical ICUs to NHSN is 2.6 per 1,000 central line days in teaching facilities and 1.9 in non-teaching facilities.

17. Number of Central Line Bloodstream Infections in Tennessee Hospitals Reporting Adult Surgical Critical Care Unit Infections Every Month, January – August, 2008 The 2007 national incidence rate for all hospitals reporting CLABSIs for adult surgical ICUs to NHSN is 3.1 per 1,000 central line days.

18. Number of Central Line Bloodstream Infections in Tennessee Hospitals Reporting Adult Medical Critical Care Unit Infections Every Month, January – August, 2008 The 2007 national incidence rate for all hospitals reporting CLABSIs for adult medical ICUs to NHSN is 2.8 per 1,000 central line days.

19. AHRQ Hospital Survey on Patient Safety Culture The Hospital Survey on Patient Safety Culture was sponsored by the Quality Interagency Coordination Task Force (QuIC), a group established to ensure that all Federal agencies involved in purchasing, providing, studying, or regulating health care services are working together and toward a common goal of improving quality care. The survey was funded by the Agency for Healthcare Research and Quality (AHRQ). The development of this safety culture assessment tool included a review of published and unpublished safety culture assessment tools and the scientific literature pertaining to safety, error and accidents, as well as error reporting. Hospital employees and managers were interviewed to identify key patient safety and error reporting issues. The TCPS makes the survey available to all safety partners at no cost

20. Value to Hospitals of Participating in the TCPS Survey You can’t fix what you don’t measure Survey results provide: –Demographic characteristics of responders –Four overall patient safety outcomes: Overall perceptions of safety Frequency of events reported Number of events reported Overall patient safety grade –Scores on ten dimensions of culture pertaining to patient safety

21. Demographic Data for Respondents, Tennessee Hospital, 2008

23. Tennessee Hospital Safety Culture Composite Scores, 2008 519 hospitals and 160,176 hospital staff respondents are included in the AHRQ national comparative data.

24. Area of Strength Graphs also are available by specific job titles( RN, PT, dietician…) work areas (ICU, medicine, pharmacy…) and whether or not the employee has direct contact with patients (yes or no) Tennessee Hospital 2008 Overall Facility Score

25. Graphs also are available by specific job titles (RN, PT, dietician…) work areas (ICU, medicine, pharmacy…) and whether or not the employee has direct contact with patients (yes or no)

26. Tennessee Hospital 2008 Overall Facility Score Area of Strength Graphs also are available by specific job titles (RN, PT, dietician…) work areas (ICU, medicine, pharmacy…) and whether or not the employee has direct contact with patients (yes or no)

27. Survey Respondent Comments from Tennessee Hospital 2008 With our current staff level and the expectations of some departments, we often feel that we are living on the edge as far as committing serious errors. I am not certain the management team is on the same page in regards to patient safety. I think the hospital strives daily to maintain a safe and error free environment. I feel that if there are errors made they are addressed immediately. Staffing is my main concern, not enough staff or some staff (same people) do not work together well thus making pt. safety issues a real concern. Poor staffing is not healthy for anyone. I can only speak for my own department. There is so much equipment we use on patients there should be more biomed techs to check equipment monthly, not after there is a breakdown. Event reporting is loose in my area, not enough guidelines taught to us about what does and does not need to be reported. I feel we are making progress with patient safety, however, shift reports and dissemination of patient information to staff is lacking. I think our hospital should be more proactive in giving feedback about errors and make the data available to everyone. Often times it seems as though quality data is kept a secret here.