1. CAUTI K-HEN Data Collection & Submission Dolores Hagan, RN BSN K-HEN Education and Data Manager August 2012

2. Objectives Review reporting requirements Review K-HEN recommended measures Review the specifications for monitoring data (Inclusion and exclusion criteria) Discuss requirements for baseline data Define data entry and submission timeline Identify measures that may be pulled from other systems where data is currently being entered 2

3. Reporting Requirements For each topic area chosen, hospitals are required to submit data for at least – One process measure AND – One outcome measure Hospitals are strongly encouraged to report on the K-HEN recommended measures Additional outcome and/or process measures may be selected and reported as desired 3

4. K-HEN Recommended Measures Purpose—standardize reporting on the same measures across the state for robust benchmarking capability Measures selected based on polling data from the KHA Quality Conference in March 2012 Have continued to evolve with your feedback (Keep it coming! ) 4

5. HRET HEN Encyclopedia of Measures Lists all measures available in the CDS Defines the numerator and denominator for each measure Provides a link to the source of the measure http://www.k- hen.com/Portals/16/Documents/HRET_HEN_ Encyclopedia_of_MeasuresV3.pdf http://www.k- hen.com/Portals/16/Documents/HRET_HEN_ Encyclopedia_of_MeasuresV3.pdf 5

6. CAUTI: Outcome Measure Preferred measure: #18, 19, 20 or 21 All tracked units, ICU, NICU or PICU CAUTI rate (device days denominator) **To capture unit specific measure, must build a custom measure. 6

7. CAUTI Outcome Measure Criteria Numerator—Symptomatic UTIs that are catheter-associated (i.e. patient had an indwelling urinary catheter at the time of or within 48 hours before onset of the event) Denominator—Number of urinary catheter days (All units tracked or specific unit) 7 http://www.cdc.gov/nhsn/pdfs/pscManual/7pscCAUTIcurrent.pdf

8. CAUTI: Process Measure Preferred Measure: #15 Urinary catheter removed on postoperative day 1 or day 2 (SCIP Inf-9) Alternate Measure: #16 UTI Prevention Catheter Bundle 8 Source: CMS SCIP Core Measures; IHI UTI Compliance Audit Tool

9. #15 CAUTI Criteria CMS Core Measure Numerator—Number of surgical patients whose urinary catheter is removed on POD 1 or POD 2 with the day of surgery being day zero Denominator—All selected surgical patients with a catheter in place postoperatively 9

10. #15 CAUTI Criteria Inclusions – Qualified SCIP cases with an ICD-9 Code of selected surgeries as defined in the Specifications Manual for National Inpatient Quality Measures Exclusions – < 18 years old – LOS > 120 or < 2 days postoperatively – Enrolled in clinical trials – Urological, gynecological or perineal procedure – ICD-9 principal procedure occurred prior to the date of admission – Discharge status expired – No urinary catheter postoperatively – ILP documentation of continued necessity – Urinary diversion or urethral catheter or intermittently catheterized prior to hospital arrival 10

11. Baseline Data Only submitted one time For all topic areas except Readmissions: – Baseline data is from 2011 prior to January 1, 2012 – May be the entire calendar year of 2011 or any other period within the year (a month, a quarter, etc) – Enter your specific period beginning and ending dates Readmission Baseline Data – Preferably CY 2011 – May use Jan – Jun 2012 if 2011 data is not available If no baseline data is available, do not enter anything for baseline—begin with monitoring data 11

12. CAUTI Baseline Data Complete baseline data entry by August 31! NHSN data will be extracted once rights are conferred Data should be entered on a monthly basis as much as possible 12

13. CAUTI 2012 Monthly Data Entry Schedule Monitoring MonthData Entry AvailableData Entry Complete JanuaryImmediatelyAs soon as possible* FebruaryImmediatelyAs soon as possible* MarchImmediatelyAs soon as possible* AprilImmediatelyAs soon as possible* MayImmediatelyAs soon as possible* JuneImmediatelyAs soon as possible* JulyAugust 1, 2012August 31, 2012 AugustSeptember 1, 2012September 30, 2012 SeptemberOctober 1, 2012October 31, 2012 OctoberNovember 1, 2012November 30, 2012 NovemberDecember 1, 2012December 31, 2012 DecemberJanuary 1, 2013January 31, 2013 13 *If data is available

14. Comprehensive Data System (CDS) Link to HRET training webinar for CDS located on K-HEN website under Data Page https://www.hretcds.org/Login.aspx Data coordinator receives initial login and creates hospital’s users – At least two data administrators – As many data entry users as needed 14

15. Measure Selection Review the K-HEN Recommended Measures and the HRET Encyclopedia of Measures Determine which measures you will report Remember you MUST report on at least one process and one outcome measure per topic area selected 15

16. Measure Enrollment Enroll in the measures that you are reporting Select Admin  Measure Enrollment – Select the topic area – Select/deselect and save the measures that you will be reporting on – This will narrow your choices for data entry to only those selected – You may reselect those measures at a later time if desired 16

17. Data Collection & Entry Review the numerator and denominator criteria for the measures selected Collect and compile the data Sign on to the CDS – Select Data Entry tab – Select the topic from the drop  Select Next – Find the appropriate measure  Select Enter Data 17

18. Baseline Data Entry Defaults to the Baseline tab Enter the Measurement start and end dates  Select ‘Add’ Under ‘Data Entry’ column, Select ‘Go’ Was data collected for this measurement period?  Select Yes or No – If No, enter reason (e.g. data not available) – If Yes, enter the numerator and denominator – Select Save or Submit Save holds data in ‘temporary’ area and is not available for reporting within the CDS Data may be edited by the hospital until it is submitted 18

19. Monitoring Data Entry Select the Monitoring tab Under the Data Entry column, Select ‘Go’ for the appropriate month Was data collected for this measurement period?  Select Yes or No If No, enter reason (e.g. data not available) If Yes, enter the numerator and denominator Select Save or Submit – ‘Save’ holds data in ‘temporary’ area and is available for reporting within the CDS – Data may be edited by the hospital until it is submitted 19

20. Data Tidbits Each month should have data entered or a reason it was not collected Additional training will be provided after data has been entered and reporting is available 20

21. Monthly Progress Report Due to K-HEN by the 10 th of each month Use template provided One report per topic area Report template and sample complete report located on K-HEN website (www.k- hen.com) under Tools and Resourceswww.k- hen.com 21

22. Aim?: (Including your How Good and By When statement) Why is this project important?: Aim Statement Changes being Tested, Implemented or Spread Recommendations and Next Steps Lessons Learned Run Charts (For each listed change, indicate whether it is being tested (T), Implemented (I) or Spread (S)) (Enter summary here) Enter summary here (what do you need from Executive Project Champion, Sponsor at this time to move project?) Recommendations Next steps for testing Project Title: ______________________________ Date: _____________ Hospital Name: ____________________________ State: _____________ © 2012 Institute for Healthcare Improvement Team Members (Name of Project Champion, Senior Leader Sponsor & all other names & roles) (Make fonts large, title, labels, dates and notes very simple on graphs prior to shrinking graphs. Should be able to fit 6-8 readable graphs here. If no data are available for a particular measures either create “empty” run list the name of the measure(s) to be collected.) Self Assessment Score, 1-5 (see AHA/HRET Assessment Scale document) = Self Assessment Score, 1-5 (see AHA/HRET Assessment Scale document) =

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24. Project Assessment Scale http://www.k- hen.com/Portals/16/Documents/HRETHEN ProjectAssessmentScale.pdf http://www.k- hen.com/Portals/16/Documents/HRETHEN ProjectAssessmentScale.pdf 24

25. Homework Set up CDS users for your site Collect and enter baseline data by Aug 31 Enter monitoring data for Jan - Jun 2012 as available and time permits Enter monitoring data for Jul 2012 by Aug 31 Complete July progress report by Aug 31 and email to info@k-hen.com (Due the 10 th of the month thereafter)info@k-hen.com 25

26. Questions 26