Learning Session 3: CDI Tracer and Assessment Tool

Transcription

1 National Nursing Home Quality Care Collaborative (NNHQCC) II and the Clostridium difficile Infection (CDI) Initiative Learning Session 3: CDI Tracer and Assessment Tool Health Services Advisory Group (HSAG) Thursday, April 19, 2018

2 Presenters Keith Chartier, MPH Associate Director Debbie Shaeffer, LPN QI Specialist Eli DeLille, RN, BSN, CIC Quality Improvement (QI) Specialist, Infection Preventionist

3 Objectives Introduce and explain HSAG s new CDI Tracer and Assessment Tool for long-term care facilities (LTCFs). Recognize gaps in your nursing home s policies and procedures. Learn how to possibly utilize the CDI Tracer and Assessment Tool in your existing Quality Assurance & Performance Improvement (QAPI) program. 3

4 What is a QIN-QIO? Funded by the Centers for Medicare & Medicaid Services (CMS) Quality Innovation Network- Quality Improvement Organization (QIN-QIO) in each state Dedicated to improving health quality at the community level Ensures people with Medicare get the care they deserve, and improves care for everyone Department of Health & Human Services Centers for Medicare & Medicaid Services 4

5 New National QIN-QIO Structure 5

6 HSAG s QIN-QIO Responsibility Nearly 25 percent of the nation s Medicare beneficiaries HSAG is the Medicare QIN-QIO for Arizona, California, Florida, Ohio, and the U.S. Virgin Islands. 6

7 QIN-QIO Areas of Focus

8 Improve Hand Hygiene and Injection Practices in ASCs* QIO Work Cardiac Health Disparities in Diabetes Adult Immunizations Transforming Clinical Practice Support of Clinicians in the Quality Payment Program Patient is at the center of care Antibiotic Stewardship in Communities Healthcare- Acquired Conditions in Nursing Homes Behavioral Health Coordination of Care *ASCs=Ambulatory Surgical Centers

9 Improve Hand Hygiene and Injection Practices in ASCs QIO Work Cardiac Health Disparities in Diabetes Adult Immunizations Transforming Clinical Practice Support of Clinicians in the Quality Payment Program Healthcare- Acquired Conditions in Nursing Homes Patient is at the center of care Behavioral Health Coordination of Care Antibiotic Stewardship in Communities

10 Improve Nursing Home Quality All nursing homes are invited to join Medicare s National Nursing Home Quality Care Collaborative (NNHQCC). An all-teach, all-learn quality improvement effort designed to ensure residents receive the highest quality of care. Collaborate with peer nursing homes and expert speakers through face-to-face meetings and webinars while earning no-cost continuing education units (CEUs). 10

11 Improve Nursing Home Quality The NNHQCC II CDI Initiative 11

12 NNHQCC II 12 *QM=Quality Measure

13 CDI Initiative 13 *NHSN=National Healthcare Safety Network

14 First, What is NHSN? National Healthcare Safety Network (NHSN) Operated by the Centers for Disease Control and Prevention (CDC) Currently utilized by hospitals Secure federal mainframe Need for Secure Access Management Services (SAMS) card 14

15 What Can NHSN Do For CDI? Facility s CDI rate (LTCF-Onset vs. On Admission) Identify not just residents, but units or neighborhoods with CDI issues Aggregate data from multiple facilities (need rights) 15

16 CDI Tracer and Assessment Tool

17 Fast Facts Spore forming bacteria Difficult to kill on surfaces Difficult to treat Reoccurs in about 1 in 5 patients who contract the illness People on antibiotics are 7 10 times more likely to get CDI and for 1 month post treatment Occurs most commonly in hospitals, nursing homes, and outpatient settings More than 80 percent of CDI deaths occur in people age 65 and older Prompt identification and appropriate treatment is crucial to improve outcomes 17 Source:

18 Feedback From Our Partners Develop tools and resources that meet the needs of post-acute partners Assistance with NHSN reporting Provide NHSN data reports Infection prevention support for CDI Gap assessment (Tracer) Education Audit tools Training 18

19 Assessment and Tracer On-site visit Performed by QIO Quality improvement specialist Engages frontline staff members Tracer methodology Focuses on flow of patient Targets high-risk areas Based on the Targeted Assessment for Prevention (TAP) Strategy 19

20 CDI Tracer and Assessment Overview NHSN data review General interview Frontline staff member interview Pharmacy interview Lab interview Dietary interview Environmental services interview Medical record review 20

21 New CDI Report from HSAG NNHQCC CDI Report 21

22 General Interview 22

23 Frontline Staff Members 23

24 Pharmacy 24

25 Lab 25

26 Dietary 26

27 Environmental Services 27

28 Medical Record Review 28

29 Testing Algorithm Resource is based on feedback from multiple partners across the QIN looking at high-risk areas of opportunity. 29

30 Hand Hygiene Audit Tool CDC and the WHO* have hand hygiene campaign information available (posters, signs, brochures, and audit tools). 30 *WHO=World Health Organization

31 Resident/Staff Education Resources are up to date, easy to understand, and available for a wide variety of subjects. 31

32 Infection Prevention (IP) Education CMS Creating an IP course Available spring 2019 On-demand No cost Topics include: IP scope of responsibilities Infection surveillance Hand hygiene Medication safety Antibiotic stewardship 32

33 How Can the CDI Tracer and Assessment Tool Fit into QAPI?

34 Worksheet to Create a Performance Improvement Project Charter (PIP) Page 1 Name of project: Practices/protocols for CDI and outbreak control Problem(s) to be solved: Improper hand hygiene, improper cleaning protocols, improper linen handling Background: Increase in the infection rate for CDI episodes Goal: Decrease # of episodes of CDI infections within 90 days Scope: CDI cases occurring on skilled unit Worksheet available at Certification/QAPI/downloads/PIPCharterWkshtdebedits.pdf 34

35 Worksheet to Create a PIP Charter Page 2 Project Approach Project Phase: Dates for initiation, planning, implementation, monitoring, and closing Project Team: Not just about who, but what is their role in this PIP Worksheet available at Certification/QAPI/downloads/PIPCharterWkshtdebedits.pdf 35

36 Worksheet to Create a PIP Charter Page 3 Barriers: Time, lack of education, location of handwashing stations Project Approval Worksheet available at Certification/QAPI/downloads/PIPCharterWkshtdebedits.pdf 36

37 PIP Page 1 Worksheet available at mance-improvement-plan-worksheet.pdf 37

38 PIP Page 1 (cont.) Worksheet available at mance-improvement-plan-worksheet.pdf 38

39 PIP Page 2 Worksheet available at mance-improvement-plan-worksheet.pdf 39

40 PIP Page 2 (cont.) Worksheet available at mance-improvement-plan-worksheet.pdf 40

41 Questions????? 41

42 HSAG NHSN Resources 42

43 Are You Receiving Monthly Updates? us to be added! Arizona California Florida Ohio

44 Contact Us! Questions? Comments? Assistance? Reach out to your state QIO. Arizona California Florida Ohio 44

45 Thank you!

46 This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for Arizona, California, Florida, Ohio, and the U.S. Virgin Islands, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. QN-11SOW-C