ESRD Network Council Meeting

Transcription

1 Mid-Atlantic Renal Coalition ESRD Network 5 NHSN Data Quality QIA 2016 Pilot - Fresenius 2016 Council Meeting 1

2 ESRD AIM Network 3 5 Reduce Costs of ESRD Care by Improving 2016 Council Meeting Care 2

3 NHSN Data Quality QIA Domain Support for Facility Data Submission to CROWNWeb, NHSN, etc. 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 June 2017; October

4 NHSN Data Quality QIA Dialysis Event Protocol 4

5 Facility Details 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 Hospital Based Source: NHSN Dialysis Practices Survey v , 2016 Note: n = 336 5

6 Facility Details 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

7 Facility Details Table: Facilities reporting 0 BSIs collected in Hospital or ED, January-June 2016 State # of Facilities Freestanding Facility Location Freestanding but owned by a hospital Hospital Based # PBCs Collected in Hospital or ED District of Columbia (D.C) Maryland Virginia West Virginia Source: NHSN Dialysis Practices Survey v , 2016 & Frequency of Dialysis Events Report Note: n = 279, 83% of Network 5 facilities have not reported a BSI collected in Hospital or ED Jan-Jun

8 NHSN Data Quality QIA Targeting Facilities Table: Criteria for Enrolling Facilities Criteria for Enrollment Targeted # of Facilities After criteria applied Average census > 50 patients Average catheter rate > than ESRD QIP Threshold of 10% Reporting 0 BSIs collected in a hospital for > 3 months Source: Denominators Report & Frequency of Dialysis Events Report Note: n = 279, facilities who have not reported a BSI collected in Hospital or ED Jan-Jun

9 NHSN Data Quality QIA Targeting Facilities 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 = 279, facilities who have not reported a BSI collected in Hospital or ED Jan-Jun

10 NHSN Data Quality QIA Pilot Facilities n = 10 Table: Pilot Facility Details State Avg. Census Avg. CVC Avg. AVG Avg. AVF Avg. Buttonhole MD Criteria for Enrollment Criteria Met Average census > 50 patients Average catheter rate > than ESRD QIP Threshold of 10% Reporting 0 BSIs collected in a hospital for > 3 months Source: Denominators Report Note: n = 10, facilities who have not reported a BSI collected in Hospital or ED Jan-Jun

11 Why Maryland? Formally designated Maryland s statewide health information exchange (HIE) by the Maryland Health Commission 11

12 CRISP Health Information Exchange Health Information Exchange (HIE): allows clinical information to move electronically among disparate health information systems. The goal of HIE is to deliver the right health information to the right place at the right time providing safer, more timely, efficient, effective, equitable, patientcentered care. 12

13 CRISP Health Information Exchange Patient Awareness All participating organizations are required to update their HIPAA Notice of Privacy Practices with a paragraph on their participation with CRISP. Marybeth Waldner is the lead for Fresenius on this if you have any specific questions. CRISP is an opt out system meaning that patients can choose to not participate 13

14 CRISP Health Information Exchange Benefits Web-based portal to access data through the HIE Access should be given to those providers and support staff who have access to patient records for treatment purposes within the dialysis facility as a course of their usual workflow Query Portal Patient demographics Lab results Positive Blood Cultures Radiology reports Medication fill history Discharge summaries History and physicals Encounter Notification System (ENS) Hospitalizations 14

15 CRISP Health Information Exchange Enrolled Hospitals Table: Hospitals receiving patients from target facilities (n=20) 1 Anne Arundel Medical Center 2 Christiana Care Hospital 3 Doctor's Community Hospital 4 UMMS Harford Memorial Hospital 5 John Hopkins Bayview Medical Center 6 MedStar Franklin Square Hospital Center 7 MedStar Good Samaritan Hospital 8 MedStar Southern Maryland Hospital Center 9 MedStar St. Mary's Hospital 10 MedStar Union Memorial Hospital 11 MedStar Washington Hospital Center 12 Meritus Medical Center 13 Northwest Hospital Center 14 Peninsula Regional Medical Center 15 Suburban Hospital 16 University of Maryland Charles Regional Medical Center 15

16 NHSN Data Quality QIA Chart: Performance and Monitoring Period for Each Cohort Source: CMS ESRD Statement of Work Note: Currently in the planning year for cohort 1 that will launch January 1,

17 NHSN Data Quality QIA Next Steps Identify project lead in your facility Identify time and day of the week for future workgroup calls 17

18 NHSN Data Quality QIA Project Importance Centers for Disease Control and Prevention 18