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

2. 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

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

4. 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

5. 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

6. Connections for the Facility Team
HRET Program Managers
Organizational Lead
Facilities
HRET
Faculty Coach
Facility Teams
Helen Plass, MA
Janine Reisinger, MPH
Amanda Wilkins, MPA

7. 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Source: Unpublished MedPAC data cited by Mor V. Health Affairs, January 2010

8. 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!

9. 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

10. 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.

11. 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

12. 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

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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. AJ Rolle, MPH
Program Manager at HRET
Measuring Progress

21. 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!

22. 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

23. Outcome Data Definitions

24. 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).

25. 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

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

27. 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

28. Facility Team Expectations
Time Commitment: 5% FTE or 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

29. 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

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

31. Cohort 5 Timeline

32. 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

33. Questions about Enrollment?
State
Organizational Lead
Contact Person AZ
Arizona Health and Hospital Association
Sandy Severson OR
Oregon Patient Safety Commission
Mary Post RI
Healthcentric Advisors
Pam Quinn
MI, MA, FL
HRET
Lindsay Kolczynski ND
Quality Health Associates of North Dakota
Michelle Alauckner SC
South Carolina Hospital Association
Diana Zona
So FL
South Florida Hospital and Healthcare Association
Linda Quick TN
Tennessee Health Care Association
Linda Estes UT
HealthInsight
Linda Egbert
Questions about Enrollment?

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