1. Cohort 1A-C Coaching Call October 1, 2014 Facilitators: Lisa Carhuff Kathy McGowan Joyce Reid

2. Learn. Act. Improve. Spread. Keep the Drum Beat Going. WELCOME and Introductions 2 What is not started today cannot be finished tomorrow

3. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 3 2014 OAT Survey Announcement Planned distribution today! Comparative survey – No changes in questions from the 2013! Suggested list for gathering input will be included for each domain Due by October 24 th 3

4. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 4 NOVI reporting of C. difficile Begin surveillance/collection of data October 1 Place October data into GHA Manual Data Entry by November 15 th Contact Jan Ratterree with any questions related to data collection surveillance and/or reporting into NOVI – (770)-240-4518 – jratterree@gha.org 4

5. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 5 What is required in Manual Data Entry to obtain accurate data: Numerator: – The number of C. difficile positive specimens in patients with specimen collection day beginning with > 3 days after admission to the facility (i.e., on or after day 4). Important Numerator Definitions: – A + test for C. difficile is defined as: A positive laboratory test result for C. difficile toxin A and/or B, OR, A toxin-producing C. difficile organism detected by culture or other laboratory means performed on a stool sample. – Do not report a Duplicate toxin-positive laboratory (+) C. difficile toxin test result with prior (+) in ≤ 2 weeks in same patient and same location 5

6. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 6 What is required in NOVI to obtain accurate data: Denominator: – Total number of Patient Days (do not count NICU and Well Baby) – A daily count of the number of patients in the facility inpatient units during a time period. To calculate patient days, for each day of the month, at the same time each day, record the number of patients. At the end of the month, sum the daily counts and enter the total. – If patient days are available from electronic databases, these sources may be used as long as the counts are not substantially different (+/_5%) from manually-collected counts 6

7. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 7 What is required in NOVI to obtain accurate data: Denominator: – We are following inpatients A patient whose date of admission to the facility and the date of discharge are different calendar days. Note: A patient who is admitted to an inpatient location as an “observation” patient is identified as an inpatient on the first and subsequent days for the purposes of surveillance. 7

8. Learn. Act. Improve. Spread. Keep the Drum Beat Going. “Reversing the Flatline” Readmissions Survey Results 8 Cohort 1 N = 41 RCA in past 3 months = 7  Reason for readmissions Transportation & Mental Health Issues

9. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 9 Readmissions Data 9

10. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 10 HAC – NOVI data entry 10

11. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 11 HAC – NOVI data entry 11

12. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 12 HAC – NOVI data entry 12

13. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 13 HAC – NOVI data entry 13

14. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 14 HAC – NOVI data entry 14

15. Learn. Act. Improve. Spread. Keep the Drum Beat Going. “It’s a wonderful life” and the HEN Project Consider the past 3 years without the HEN – What has made the difference for your hospital – Tell the “HEN story” for your hospital 15

16. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 16 Cohort 1 – Safety Across the Board Share additional successes on any HEN Topic Best Practice Implementation questions? Any questions/comments regarding measures? 16

17. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Upcoming Events Next Cohort Coaching Call: Not Scheduled HEN Celebration Webinar tentatively scheduled for November 19 Data Submission – August Data Due October 15: ADE’s including INR, BG, and Opioids Falls with injury VTE-6 (due once a quarter) HAI (if not submitting via NHSN) include CDI EED if applicable

18. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 18 EVALUATION Remember Complete the evaluation for today’s Cohort 1 Coaching Call! 18