Improving NHSN Data Quality Capturing Positive Blood Cultures Identified in Hospitals

Transcription

1 Improving NHSN Data Quality Capturing Positive Blood Cultures Identified in Hospitals 1

2 Agenda Fresenius Clinic Participation Historical Overview NHSN Reporting Dialysis Clinic Selection Review Project Planning 2016 Details about CRISP HIE Next Steps Facility Homework 2

3 Fresenius Dialysis Clinics Team CCN Clinic # FACILITY NAME Pilot? Capitol BMA - CAMP SPRINGS Yes Capitol Washington Yes Capitol BMA - BALTIMORE Yes Capitol BMA - LEONARDTOWN No Capitol QUALITY CARE DIALYSIS - SOUTHERN MARYLAND Yes Capitol FMC - LAPLATA Yes Capitol BMA - SOUTH ANNAPOLIS Yes Capitol FMC OF PORTER DIALYSIS - WHITE MARSH No Capitol FMC - WALDORF No Capitol FMC - PRINCE GEORGES COUNTY DIALYSIS Yes Capitol RAI - CHILLUM-HYATTSVILLE No Capitol FMC OF PORTER DIALYSIS - PIKESVILLE No Capitol FMC - FORT FOOTE Yes Capitol FMC - SURRATTS Yes Capitol FRESENIUS MEDICAL CARE ESSEX DUNDALK, LLC No Eastern PA/Delaware FMC - ELKTON No Eastern PA/Delaware FMC - SALISBURY No Eastern PA/Delaware FMC - NORTH SALISBURY No Eastern PA/Delaware FMC - PRINCESS ANNE No Western Pennsylvania FMC - HAGERSTOWN No 3

4 Let s get up to speed, how far have we come in NHSN reporting? 4

5 Historical Overview 2011: CMS published final rule for the ESRD Quality Incentive Program measures including NHSN Dialysis Event Reporting Measure 2012: First performance year for NHSN Dialysis Event Reporting Measure 2014: First payment year for NHSN Dialysis Event Reporting Measure 2016: For this payment year the NHSN Dialysis Event Reporting Measure moved from a reporting to a clinical measure Simply, it matters what your data says now 5

6 Network 5 NHSN Work NHSN Monthly Data Checks In previous CMS contracts the Network was tasked with performing monthly NHSN data checks using CDC-created checklist and reporting results to CMS NHSN Bi-Annual Surveys The Network also reviewed facilities with the highest and lowest BSI rates bi-annually to review: Surveillance practices using CDC survey tool Report on BSI prevention practices 6

7 What did we learn from these activities? Figure: Low Reporting of Hospital BSIs Root Cause Analysis Diagram Source: 2015 NHSN Bi-Annual Surveys completed by ESRD Network 5 7

8 Required BSI Reporting Dialysis Event Protocol Figure: Dialysis Event Protocol Excerpt Source: CDC Dialysis Event Protocol 8

9 Required BSI Reporting Dialysis Event Protocol Figure: Reportable Positive Blood Cultures Collected in a Hospital Source: CDC NHSN Training recording available on our website 9

10 Problems and CMS Direction Bloodstream Infections (BSIs) are problematic accounting for a substantial number of hospitalizations for dialysis patients Active collection and use of surveillance data is critical for any BSI prevention program Dialysis providers are challenged by incomplete transfer of pertinent clinical data from their patients hospitalizations CMS Statement of Work The Network is tasked with planning and performing quality improvement activities to increase facility reporting BSIs among dialysis patients that are identified within one calendar day following hospital admission. 10

11 Project Overview Domain Support for Facility Data Submission to NHSN Scope Minimum of 20 facilities and 5 hospitals Objective Identify dialysis facilities without EMR access and affiliated hospitals Implement activities to improve communication of key information between hospitals and facilities using RCA and the PDSA cycle Goal Increase reporting of BSIs collected in a hospital by June

12 How was my clinic selected? 12

13 NHSN Data Review The Network reviewed: 1. Facility Location freestanding, freestanding but owned by a hospital, and hospital-based 2. Reported bloodstream Infections by state 3. Reported BSIs by location hospital collected or dialysis facility collected 4. Facilities with high long-term catheter rates 5. Clinic census (patient-months) 13

14 Facility Location Table: Description of Network 5 Dialysis Facilities reporting to NHSN State # of Facilities Freestanding Facility Location Freestanding but owned by a hospital District of Columbia (D.C) Maryland Virginia West Virginia Source: NHSN Dialysis Practices Survey v , 2016 Note: n = 336, Network 5 has more freestanding facilities located in Maryland and Virginia Hospital Based 14

15 Reported BSIs by Location Table: Reported BSIs stratified by Dialysis Facility Location, January-June 2016 Dialysis Facility Location # of Facilities # PBCs Collected in Hospital or ED # BSIs Reported % of PBCs Reported Freestanding % Freestanding but owned by a hospital % Hospital Based % Source: NHSN Frequency of Dialysis Events Table Note: n = 336, January-June 2016, while we have more freestanding facilities our hospital-associated clinics have higher reporting rates of PBCs collected in a hospital 15

16 Inclusion/Exclusion Criteria 1. Facility average census must be greater than 50 patients/month 2. Average catheter rate must be greater than the ESRD QIP threshold, > 10.00% 3. Facility must have reported 0 BSIs collected in a hospital for > 3 months within the baseline timeframe (Jan-Jun 2016) 16

17 Dialysis Facilities with criteria applied Table: Final Target Facilities State # of Facilities # PBCs Collected in Hospital or ED District of Columbia (D.C) 14 0 Maryland 73 0 Virginia 75 0 West Virginia 12 0 Source: Denominators Report & Frequency of Dialysis Events Report Note: n = 174, facilities who have not reported a BSI collected in Hospital or ED for > 3 months during Jan-Jun Identified Virginia and Maryland as areas for opportunity 17

18 Virginia or Maryland? Healthcare Quality Innovators (HQI) introduced Network 5 to CRISP Chesapeake Regional Information System for our Patients (CRISP) Regional Health Information Exchange (HIE) serving Maryland and the District of Columbia Answer: Maryland because we have an available intervention to improve the transfer of information from the hospital to the dialysis center electronically 18

19 What is an HIE? HIEs allow clinical information to move electronically among disparate health information systems 19

20 What is the goal of a HIE? Deliver the right health information to the right place at the right time to ensure care is: Safer Timelier Efficient Effective Equitable Patient-Centered 20

21 What has happened up until this point? 21

22 Project Timeline FEBRUARY MARCH APRIL MAY JUNE JULY Legal & Compliance Legal & Compliance Legal & Compliance AUGUST SEPTEMBER OCTOBER In October 2016, we received approval to start onboarding clinics into a pilot to prepare for the launch of this project Monday, January 2 nd. 22

23 Fresenius Pilot Team CCN Clinic # FACILITY NAME Pilot? Capitol BMA - CAMP SPRINGS Yes Capitol Washington Yes Capitol BMA - BALTIMORE Yes Capitol FMC - PRINCE GEORGES COUNTY DIALYSIS Yes Capitol QUALITY CARE DIALYSIS - SOUTHERN MARYLAND Yes Capitol FMC - LAPLATA Yes Capitol BMA - SOUTH ANNAPOLIS Yes Capitol FMC - FORT FOOTE Yes Capitol FMC - SURRATTS Yes Paved the way for specific tasks associated with launching this project. All 9 clinics have access to ENS PROMPT to receive alerts on their patients 23

24 Tell me more about CRISP 24

25 Hospital Connectivity CRISP currently receives information pertaining to ED visits and inpatient admissions in real-time from: All Maryland hospitals (49) All D.C. Hospitals (9) 6 Delaware Hospitals INOVA hospitals in Northern Virginia (5) 3 West Virginia Hospitals A number of long-term care facilities 25

26 System Features Encounter Notification Services (ENS) Sends a secure message to providers for active patients in the clinic. Alerts such as: Hospital Admission Hospital Discharge Emergency Room Visit CRISP Clinical Query Portal Gives providers the ability to securely look up patient information through the internet. Retrieves clinical data from participants and displays it in a viewonly screen at the point of care. 26

27 CRISP Clinical Query Portal Access to real-time clinical information from all CRISP participants including: Lab results Radiology reports Discharge summaries History and physicals Consultations Operative notes Transfer summaries Prescription drug monitoring program (PDMP) data ImmuNet 27

28 ENS Proactive Management of Patient Transitions (ENS PROMPT) ENS PROMPT is a secure, web-based tool to help facilities better manage notifications. Features Encounter alerts stream continuously in real time Advanced, custom filter options, with the ability to save custom filters for easy reuse Download alert data in spreadsheet format View data spanning the past 30 days Search patients by name or medical record number (MRN) Manage notifications by status use ENS PROMPT s real0time tracking feature to mark patients complete and streamline workflow View patients readmission count 28

29 ENS PROMPT Figure: Screenshot of CRISP ENS PROMPT Source: Youtube - CRISP ENS PROMPT Demo v

30 Next Steps 30

31 Clinic To-Do List 1. Complete CRISP ENS Prompt checklist and submit via to by Wednesday, December 7 th Once you have been registered in the system by CRISP you will receive an enrollment with credentials to login into the system 2. Attend ENS PROMPT Training with CRISP Thursday, December 15 th 31

32 ENS PROMPT Checklist Figure: Screenshot of CRISP ENS PROMPT Checklist Source: CRISP Clinic Manager, 1 Additional RN, secretary, Director of Operations (DO), RVP Capitol facilities only 32

33 Important Note In order to get access to ENS PROMPT you must have a Fresenius address Clinic managers can request addresses for staff without Fresenius addresses 33

34 Tentative Plan to prepare for 2017 Kickoff ENS PROMPT Training: Thursday, Dec. 15 th CRISP Query Portal Training: Thursday, Dec. 29 th Go Live: Monday, January 2 nd **Dialysis Facilities will not have access to the query portal until after they have received training 34

35 2017 Project Calls/Webinar 35

36 Questions/Comments/Concerns? Contact Amber Paulus, Project Manager Cell: