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QSource Update: Reducing Hospital Infections Manoj Jain, MD, MPH Medical Director, QSource 11 March, 2009 - Memphis 17 March, 2009 - Knoxville 26 March, 2009 - Nashville
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QSource Update: Reducing Hospital Infections Manoj Jain, MD, MPH Medical Director, QSource 11 March, 2009 - Memphis 17 March, 2009 - Knoxville 26 March,

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Page 1: QSource Update: Reducing Hospital Infections Manoj Jain, MD, MPH Medical Director, QSource 11 March, 2009 - Memphis 17 March, 2009 - Knoxville 26 March,

QSource Update: Reducing Hospital Infections Manoj Jain, MD, MPH

Medical Director, QSource

11 March, 2009 - Memphis

17 March, 2009 - Knoxville

26 March, 2009 - Nashville

Page 2: QSource Update: Reducing Hospital Infections Manoj Jain, MD, MPH Medical Director, QSource 11 March, 2009 - Memphis 17 March, 2009 - Knoxville 26 March,

Objectives for Today:

• Vision/Mission • Major Initiatives in TN by QIO and TN Center for

Patient Safety (TCPS) on MRSA/SCIP • QSource/TCPS MRSA/SCIP Crosswalk• Model for Change Within the MDRO Module• Other Present and Future Initiatives • Preparing for the Future

Page 3: QSource Update: Reducing Hospital Infections Manoj Jain, MD, MPH Medical Director, QSource 11 March, 2009 - Memphis 17 March, 2009 - Knoxville 26 March,

“The right carefor every person,every time.”

CMS Vision Statementfor the National Healthcare Quality Improvement Program

Page 4: QSource Update: Reducing Hospital Infections Manoj Jain, MD, MPH Medical Director, QSource 11 March, 2009 - Memphis 17 March, 2009 - Knoxville 26 March,

• Safe

• Timely

• Effective

• Efficient• Equitable

• Patient-centered The Institute of Medicine

The “Right Care”

Page 5: QSource Update: Reducing Hospital Infections Manoj Jain, MD, MPH Medical Director, QSource 11 March, 2009 - Memphis 17 March, 2009 - Knoxville 26 March,

• History• Recruitment• Measures• Intervention• Evaluation

MRSA and SCIP – QSource and TCPS

Two Parallel, Overlapping, andSynergistic Initiatives

Page 6: QSource Update: Reducing Hospital Infections Manoj Jain, MD, MPH Medical Director, QSource 11 March, 2009 - Memphis 17 March, 2009 - Knoxville 26 March,

Historical Perspectives:

• Aug 2008 thru July 2011 – 3 year timeframe

• Funding from CMS through QIOs

• Clinical Advisors - Manoj Jain, MD, MPH; Marion Kainer, MD

• Team Leaders – QSource Patient Safety Team

• Jan 2008 thru Jan 2010 – 2 year timeframe

• Funding from TN BC-BS Health Foundation thru THA TCPS

• Clinical Advisors – Peter Pronovost, MD & Chris Goeschel; Marion Kainer, MD

• Team Leader - V/P and Director TCPS

Page 7: QSource Update: Reducing Hospital Infections Manoj Jain, MD, MPH Medical Director, QSource 11 March, 2009 - Memphis 17 March, 2009 - Knoxville 26 March,

Recruitment Outcomes:

• MRSA

30 Hospitals

• SCIP

22 Hospitals

• MRSA

63 Hospitals

• SCIP

69 Hospitals

Page 8: QSource Update: Reducing Hospital Infections Manoj Jain, MD, MPH Medical Director, QSource 11 March, 2009 - Memphis 17 March, 2009 - Knoxville 26 March,

SCIP Measure Comparisons:

• SCIP Inf-1 Antibiotic Administration within One Hour Before Incision

• SCIP Inf-2 Use of Antimicrobial Recommended in Guideline

• SCIP Inf-3 Antibiotic Discontinuation within 24 Hours of Surgery End

• SCIP Inf-4 Glucose Control in Cardiac Surgery Patients

• SCIP Inf-6 Appropriate Hair Removal • SCIP-VTE-1 Recommended VTE

Prophylaxis Ordered• SCIP-VTE-2 Received Appropriate VTE

Prophylaxis within 24 Hours After Surgery

• SCIP Inf-1 Antibiotic Administration within One Hour Before Incision

• SCIP Inf-2 Use of Antimicrobial Recommended in Guideline

• SCIP Inf-3 Antibiotic Discontinuation within 24 Hours of Surgery End

• SCIP Inf-4 Glucose Control in Cardiac Surgery Patients

• SCIP Inf-6 Appropriate Hair Removal • SCIP Inf-7 Normothermia• SCIP-VTE-1 Recommended VTE

Prophylaxis Ordered• SCIP-VTE-2 Received Appropriate VTE

Prophylaxis within 24 Hours After Surgery

Page 9: QSource Update: Reducing Hospital Infections Manoj Jain, MD, MPH Medical Director, QSource 11 March, 2009 - Memphis 17 March, 2009 - Knoxville 26 March,

MRSA Measure Comparisons:

• MRSA-1 MRSA Infection Rate – MRSA healthcare-associated infections that are not present or incubating on admission to the identified unit

• MRSA-2 Hospital Onset MRSA Incidence Rate Based on Clinical Cultures – a proxy measure of MRSA infections based on clinical cultures that have a hospital-onset

Required:• # of Admissions to Specific Unit During

Reporting Period or Facility Wide • # of Patient Days in Specific Unit

During Reporting Period or Facility Wide

• Hospital Onset MRSA (all cultures)

Optional Measures Also Reportable (See Crosswalk)

Page 10: QSource Update: Reducing Hospital Infections Manoj Jain, MD, MPH Medical Director, QSource 11 March, 2009 - Memphis 17 March, 2009 - Knoxville 26 March,

MRSA/SCIP Intervention Similarities:

• Intensive Approach• Onsite visits• Assistance with AHRQ

Survey• Teach TeamSTEPPS

Methodology• Conference Calls• Webinars

• Broader Approach• Regional Workshops• Statewide Meetings• Monthly Conference Calls• Assistance with AHRQ

Survey• Webinars

Page 11: QSource Update: Reducing Hospital Infections Manoj Jain, MD, MPH Medical Director, QSource 11 March, 2009 - Memphis 17 March, 2009 - Knoxville 26 March,

MRSA/SCIP Parallel Reporting Techniques:

• SCIP – monthly throughTCPS Website

• MRSA – monthly throughMDRO Module

• SCIP – monthly throughTCPS Website

• MRSA – monthly throughTCPS Website

Page 12: QSource Update: Reducing Hospital Infections Manoj Jain, MD, MPH Medical Director, QSource 11 March, 2009 - Memphis 17 March, 2009 - Knoxville 26 March,

MRSA/SCIP Evaluation and Feedback Comparisons:

• Monthly data feedback with comparisons/benchmarks

• Monitor closely andintervene as needed

• Monthly data feedbackwith comparisons/benchmarks

• Provide assistanceas requested

Page 13: QSource Update: Reducing Hospital Infections Manoj Jain, MD, MPH Medical Director, QSource 11 March, 2009 - Memphis 17 March, 2009 - Knoxville 26 March,

Summary of Parallel Initiatives:

• Collecting Many of the Same Measures• AHRQ Survey• Monthly Reporting of Measures• Conference Calls with Clinical Advisors• Monthly Feedback of Data with Benchmarking

Data/Comparison to Other Collaborators

Page 14: QSource Update: Reducing Hospital Infections Manoj Jain, MD, MPH Medical Director, QSource 11 March, 2009 - Memphis 17 March, 2009 - Knoxville 26 March,

Health Research and Educational Trust (HRET)

• Effort to Replicate Successes of Michigan Keystone Project Nationally

• Conducting in Conjunction with American Hospital Association (AHA)

• Comprehensive Unit-Based Safety Program (CUSP) – Can Be Focused on Any Topic

• To Pilot Soon in 10 States Through QIOs and State Hospital Associations

• TN is Ahead of the Game Thanks to THA/TCPS!

Page 15: QSource Update: Reducing Hospital Infections Manoj Jain, MD, MPH Medical Director, QSource 11 March, 2009 - Memphis 17 March, 2009 - Knoxville 26 March,

MDRO Module – Present CDC/CMSModel for Change

Page 16: QSource Update: Reducing Hospital Infections Manoj Jain, MD, MPH Medical Director, QSource 11 March, 2009 - Memphis 17 March, 2009 - Knoxville 26 March,

Key Elements of MDRO Module

• Use of Module to Monitor at Least One Inpatient Unit with High MRSA Rates

• Enables Hospitals to Conduct MRSA “Infection Surveillance” and Lab-ID Event Reporting”

• Enables Hospitals to Collect Data on Process Measures (Hand Washing, BarrierPrecautions, etc.)

• Hospitals Can Also Choose to Collect Data on CDAD

Page 17: QSource Update: Reducing Hospital Infections Manoj Jain, MD, MPH Medical Director, QSource 11 March, 2009 - Memphis 17 March, 2009 - Knoxville 26 March,

When MDRO Module goes “Live”:

• Statewide QSource Trainings in Collaboration with Dr. Marion Kainer on the Electronic Tool/Module

• Tentatively Scheduled for April 2009• To be Held in 3 Cities Across the State• CMS Baseline Timeframe Began 2/1/09• Monthly Data Entry Expectation

Page 18: QSource Update: Reducing Hospital Infections Manoj Jain, MD, MPH Medical Director, QSource 11 March, 2009 - Memphis 17 March, 2009 - Knoxville 26 March,

Other QSource and TCPS Initiatives:

QSource:• Crossing the Continuum – NH and

Hospital Pressure Ulcer Project• Drug Safety – Looking at Potentially

Inappropriate Medications and Drug-to-Drug Interactions in Part D Data

TCPS:• Central Line Blood Stream Infections

(CLBSI)

Page 19: QSource Update: Reducing Hospital Infections Manoj Jain, MD, MPH Medical Director, QSource 11 March, 2009 - Memphis 17 March, 2009 - Knoxville 26 March,

Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU):

• March 12th THA/QSource Webinar on the Release of the Dry Run Version of Hospital Specific Reports on AHRQ Measures

• Latest HQA Preview Report for Discharge Quarters Q3 07 through Q2 08 – Withholding Period Ended 2/17/09; to go Live on Hospital Compare March 2009

Page 20: QSource Update: Reducing Hospital Infections Manoj Jain, MD, MPH Medical Director, QSource 11 March, 2009 - Memphis 17 March, 2009 - Knoxville 26 March,

Next QSource Statewide Abstraction Clinic:

• March 19, 2009 from 9:00-10:30 CST• To Highlight Changes to Q2/Q3 2009

Specifications Manual and Abstraction Guidelines

Page 21: QSource Update: Reducing Hospital Infections Manoj Jain, MD, MPH Medical Director, QSource 11 March, 2009 - Memphis 17 March, 2009 - Knoxville 26 March,

Why Do Some Hospitals Succeed?JAMA May 23/30, 2001 vol285, No 20

• Shared Goals for Improvement• Substantial Administrative Support• Strong Physician Leadership• Credible Data Feedback

Page 22: QSource Update: Reducing Hospital Infections Manoj Jain, MD, MPH Medical Director, QSource 11 March, 2009 - Memphis 17 March, 2009 - Knoxville 26 March,

5 Strategies to Stay Off “The List”!

• Prepare – Know Your Numbers• Have a Team to Deploy/Assist with Efforts• Learn and Teach QI to All – IP/Nurse Manager/

Front Line Staff• Make a Business Case for Infection Prevention• Get Leadership Engaged and Boards on Board

Page 23: QSource Update: Reducing Hospital Infections Manoj Jain, MD, MPH Medical Director, QSource 11 March, 2009 - Memphis 17 March, 2009 - Knoxville 26 March,

What QI/IP Staff Need to Be Doing NOW

• You are the Change Agent and Knowledge Base for Quality Improvement and Infection Prevention in Your Institution.

– Culture Change/Work Together– Institute Concurrent Care Management– Standardize Infection Processes (Use “Opt Out”

Approach for Order Sets)– Conduct Informal “RCA” of Cases that Fall Out– Engage Physicians – ASK Frontline Staff and Feedback Data Regularly

Page 24: QSource Update: Reducing Hospital Infections Manoj Jain, MD, MPH Medical Director, QSource 11 March, 2009 - Memphis 17 March, 2009 - Knoxville 26 March,

“The right carefor every person,every time.”

CMS Vision Statementfor the National Healthcare Quality Improvement Program

Page 25: QSource Update: Reducing Hospital Infections Manoj Jain, MD, MPH Medical Director, QSource 11 March, 2009 - Memphis 17 March, 2009 - Knoxville 26 March,

Manoj Jain, MD, MPH

Medical Director, QSource

Thank You!

This presentation and related materials were developed by QSource, the Medicare Quality Improvement Organization for Tennessee, under contract with the Centers for Medicare & Medicaid Services (CMS), a division of the Department of Health and Human Services. Contents do not necessarily reflect CMS policy. QSOURCE-TN-109.62-2008-15

QSource Update: Reducing Hospital Infections