Best Care Always Summary of General Ward Measures (November 2013)

Best Care Always Summary of General Ward Measures (November 2013) Introduction This document provides a summary of the core measures and operational definitions used in the Hamad Medical Corporation s Best Care Always Campaign General Ward work stream. The document is laid out as follows: The first column on each page provides the Measure Name The second column provides the Extranet Identifier for each measure The third column provides the Operational Definition for each measure The fourth column provides Data Collection Guidance The Extranet Identifier contains the following information: The first two letters of the Extranet Identifier indicate the work stream: o Critical Care (CC), o General Ward (GW) or o Peri-operative (PO) The third letter in the Extranet Identifier indicates if the measures is an: o Outcome measure (O) o Process measure (P) Finally the fourth item in the Extranet Identifier is the sequential number for each measure. Note that the measures are sequentially numbered within the Outcome and Process list of measures. For example, consider the following Extranet Identifier, GWO1. This is referring to General Ward (GW), outcome (O) measure number 1 (GWO1). Similarly GWP1 refers to General Ward (GW) process (P) measure number 1. This labeling convention applies to all the measures listed in this document. Page 0

Finally, note that: Not all the measures listed in this document will be required at the outset of the campaign. Some of the measures will be phased in over time as a hospital moves from the initial testing in a pilot ward or department to the whole hospital. If a hospital does not provide a service related to a particular measure, this measure can be ignored. Questions about these measures should be directed to: Dr. Robert Lloyd, Executive Director Performance Improvement, Institute for Healthcare Improvement (rlloyd@ihi.org), and Ms. Kate Jones, AED Patient Safety, Medical, Academic and Research Affairs, Hamad Medical Corporation (CJones@hmc.org.qa) Page 1

General Ward Measures: This document identifies the high level measures for the general ward work stream. For each measure the following pieces of information are presented: Measure Name o Outcome Measures GWO1 GWO7 o Process Measures GWP1 GWP9 Operational Definition (which provides the specific details on the components of the measure, e.g., numerator and denominator) Data Collection Guidance (which provides suggestions on how to obtain the data (including sampling recommendations)) Outcome Measures Measure Name Extranet Identifier Operational Definition Data Collection Guidance Incidence (rate) of inpatient hospitalonset Clostridium Difficile Infection (CDI) GWO1 Numerator: the number of all incident laboratory-identified (LabID) events identified >3 days after admission to the facility Denominator: Patient days Include: All Laboratory-Identified (LabID) Events: All non-duplicate C. difficile toxin-positive laboratory results Duplicate C. difficile-positive test: Any C. difficile toxin-positive laboratory result from the same patient and location, following a previous C. difficile toxin-positive laboratory result within the past two weeks (14 days) (even across calendar months). There should be a full 14 days with no C. difficile toxin-positive laboratory result for the patient and location, before another C. difficile LabID Event is counted in the Numerator for the patient and location. The date of specimen collection is considered Day 1. Exclude: Tests related to active surveillance testing Community-onset CDI laboratory-identified (LabID) events identified <3 days after admission to the facility (i.e., day 1, 2, or 3) Data from patients who are not assigned to an inpatient bed. These include outpatient clinic and emergency department visits Note: This measure follows the operational definition published in Qatar Health Service Performance Agreements (HSPA) Project 2.1.6, Procedures Manual for Hospitals, August 20, 2013. Page 2

Days between a C. difficile associated disease occurrence GWO2 This measure is a cumulative count of the number of days that have gone by with no C. difficile associated disease being reported. Every time a C. difficile associated disease occurs the count is started over again. The longer the run of cumulative successes (days with no C. difficile associated disease occurring) the better the outcome. Whenever events occur that are relatively rare in nature or when a ward or pilot area has sufficiently small numbers of events, the preferred way to analyze the data is to plot: (1) successful cases between the occurrence of a C. difficile event, or (2) the days between C. difficile events. Both of these techniques (i.e., calculating a rate as well as days between events) may be used. Typically the C. difficile rate will serve as the starting point. When events become low or rare then the measure will change to be a count of the days between a C. difficile episode. Incidence (rate) of inpatient hospitalonset Methicillinresistant Staph. aureus GWO3 Numerator: Number of all unique blood source laboratory-identified (LabID) events identified >3 days after admission to the facility. Denominator: Patient days Ask someone to conduct a data entry audit on a random set of 20% of all cases entered after entering 100 cases. If errors exceed 50%, it is advisable to repeat data entry for the 100 cases. Note: This measure follows the operational definition published in Qatar Health Service Performance Agreements (HSPA) Project 2.1.6, Procedures Manual for Hospitals, August 20, 2013.See pages 190-200 in the SCH Procedures Manual for details on what is to be included and excluded when submitting data for this measure. Days between Staph. aureus Bacteraemias GWO4 This measure is a cumulative count of the number of days that have gone by with no SABs being reported. Every time a SAB occurs the count is started over again. The longer the run of cumulative successes (days with no SABs occurring) the better the outcome. Whenever events occur that are relatively rare in nature or when a ward or pilot area has sufficiently small numbers of events, the preferred way to analyze the data is to plot: (1) successes between failures, or (2) time between failures. Page 3

Urinary catheterassociated urinary tract infections rate GWO5 Numerator: the number of patients with a urinary catheter who are being treated for a UTI arising from their current inpatient stay Include all patients with a urinary catheter who have a newly diagnosed UTI where the definition for a CAUTI is met per local guidelines. Denominator: the total number of indwelling urinary catheter days The CAUTI rate is calculated by dividing the numerator by the denominator and then multiplying the result by 1000 to create the CAUTI rate per 1000 catheter days Number of patients with a Venous Thromboembolism arising from a current inpatient stay or a new Venous Thromboembolism arising where there is a history of admission to hospital within the last 3 months GWO6. Note: the development of the final set of VTE measures and operational definitions is presently underway. These measures will be included as soon as they are made available. Pressure ulcer count GWO7 This is a cumulative count of the number of pressure ulcers acquired within the general ward setting. Patients should be assessed for pressure ulcers on a daily basis. Each time a patient has acquired a pressure ulcer (a new case), it should be recorded. All patients in the pilot unit should be assessed for pressure ulcers. No sampling is needed. Page 4

Process Measures Percent compliance with hand hygiene GWP1 Numerator: the total number of opportunities in the sample where appropriate hand hygiene was conducted Denominator: the total number of opportunities in the sample for appropriate hand hygiene compliance Calculate the percent compliance with hand hygiene by dividing the numerator by the denominator and then multiplying the resulting proportion by 100 The sample of patients for this measure will come from monthly observations of patient care encounters. Data will be reported monthly, however it is collected weekly. Each week the designated observer(s) should observe five different providers during an opportunity for hand hygiene. The observer task can be rotated among staff in order to reduce the likelihood that individuals may increase compliance because they knew that a designated individual was conducting the observations. The sample should produce a total of 5 opportunities (the denominator) for hand hygiene per week or 20 per month. The sampling approach is to select a random day each week to conduct the observation of clinicians and other employees who actually touch a patient. This can be done ahead of time in order to set up observers on the designated days. For example, the opportunities may be based on the World Health Organization s (WHO) 5 Moments: o Before patient contact o Before aseptic task o After body fluid exposure risk o o After patient contact After contact with patient surrounding In this case "appropriate" hand hygiene is defined as the observer witnessing that the health care provider (e.g., consultant, nurse, technician, etc) properly cleaned their hands (soap and water or alcohol gel) before contacting the patient and after contact with the patient was made. Page 5

Percent compliance with the urinary catheter insertion bundle Percent compliance of patients deemed at risk receiving the full pressure ulcer prevention bundle GWP2 Numerator: the number of patients with urinary catheters inserted during the month receiving all bundle components at the designated time Denominator: the number of patients with urinary catheters reviewed during the month The percent compliance is calculated by dividing the numerator by the denominator and then multiplying the resulting proportion by 100 GWP3 Numerator: the number of patients deemed at risk receiving full pressure ulcer prevention Denominator: the number of at risk patients with pressure ulcers Calculate the percentage by dividing the numerator by the denominator and then multiplying the resulting proportion by 100 There should be no sampling for this measure. All patients who have a urinary catheter inserted should be reviewed for compliance. All elements of the bundle must be met. If your percent compliance is low, measure each element of the bundle individually o The numerator would be the number of eligible patients who received the element of the bundle o The denominator would be the total number of eligible patients o The percent would be calculated by dividing the numerator by the denominator and multiplying by 100 Use local guidelines for at risk criteria. There should be no sampling for this measure. All patients deemed at risk should be reviewed for compliance. All elements of the bundle must be met. If your percent compliance is low, measure each element of the bundle individually. o The numerator would be the total number of at risk patients who received the element of the bundle o The denominator would be the number of at risk patients o The percentage would be calculated by dividing the numerator by the denominator and multiplying by 100 Page 6

Percent of patients receiving daily pressure ulcer risk reassessment GWP4 Numerator: the number of patients receiving daily pressure ulcer risk reassessment Randomly select 5 patients per week and record the information weekly. Tally up the total at the end of the month and enter the aggregate number into the Extranet. Percent of eligible patients receiving VTE prophylaxis GWP5 Denominator: the number of patients with pressure ulcers reviewed Calculate the percentage by dividing the numerator by the denominator and then multiplying the resulting proportion by 100 Note: the development of the final set of VTE measures and operational definitions is presently underway. These measures will be included as soon as they are made available. Percent achievement of multi-disciplinary rounds(mdrs) GWP6 Numerator: the total number of patients on the ward who had MDRs on the day of the study Randomly select one day per week to select a sample of patients eligible for MDRs. Look for documented evidence in the patient s chart of a completed MDR. Denominator: the total number of patients on the ward on the day of the study The percent achievement of multi-disciplinary rounds is calculated by dividing the numerator by the denominator and multiplying the result by 100 Each week a minimum sample of 5 patients should be selected for a total of 20 patients for the month. Enter data into the IHI Extranet with appropriate annotations to document issues related to data collection (e.g., how you randomly select the day of the week for the study). While you will collect the data weekly (and use that data for improvement within your team), you will aggregate it and the report monthly on the IHI Extranet. Page 7

Percent achievement of multi-disciplinary rounds and daily goals (DG) Percent compliance with using daily safety briefings GWP7 Determine the numerator: the total number of patients with MDRs who also had DGs documented Determine the denominator: the total number of patients who had MDRs The percent achievement of daily goals is calculated by dividing the numerator by the denominator and multiplying the result by 100 GWP8 Numerator: the total number of days in the month in which at least one safety briefing was conducted in the pilot unit Denominator: the total number of days in the month The percent compliance with using daily safety briefings is calculated by dividing the numerator by the denominator and then multiplying the resulting proportion by 100 One day per week (the same day as the MDRs sample collection), conduct a review of the patients you pulled for the MDRs sample. Look for documented evidence of DGs in this sample. Rotate data collection days of the week and shifts in order to avoid "data collection" fatigue and the possibility of having staff change their behaviors because they know the day of the week that will be used to observe this measure. Remember that the denominator for this measure is the number of patients who had MDRs. If you sampled appropriately the denominator should be 20 patients. Enter data into the IHI Extranet with appropriate annotations to document issues related to data collection (e.g., how you randomly select the day of the week for the study). While you will collect the data weekly (and use that data for improvement within your team), you will aggregate it and the report monthly on the IHI Extranet. Safety briefings are an integral part of developing a culture of safety. They are used to help increase staff awareness of patient safety issues, create an environment in which staff share information without fear of reprisal, and integrate the reporting of medication safety issues into daily work. It is recommended to start with one safety briefing a day and then continue to add safety briefings at other points throughout the day as appropriate. One of the keys to successful safety briefings is to make sure that the information generated in the briefing session is passed along to the next shift. If, for example, the safety briefing is held at the start of the day shift then the information gathered during this session should be passed along to the second shift and then after adding their findings they should pass the briefing on to the next shift and so on. This cascading approach to information transfer is a central part of knowledge management and creating a culture of safety. Page 8

Percent of RN-doctor exchanges about patients with a change in condition that were based on an SBAR format GWP9 Numerator: the number of RNdoctor exchanges about patients with a change in condition that were based on an SBAR format Denominator: the number of patients with a change in condition that required a RNdoctor consult All patients with a change in condition should be included in the denominator. There should be no sampling for this measure. A change in condition can include but not be limited to: fluctuating vital signs, a dramatic increase or decrease in vital signs, a report by a family member or care giver that the patient does not seem right or any other assessment that even suggests that the patient is not in a stable and predictable state. The percent of exchanges in which an SBAR format was used is calculated by dividing the numerator by the denominator and then multiplying the resulting proportion by 100 Percent compliance with Early Warning Score Assessment This measure will be phased in Numerator: the total number of observations with an Early Warning Score documented Denominator: the total number of observations Calculate the percent compliance with the Early Warning Score Assessment by dividing the numerator by the denominator and multiplying by 100 Inclusion Criterion: Patients admitted > 24 hours (excluding midwifery, pediatric /neonatal and non-acute areas such as continuing care). The Early Warning Score (EWS) is a tool for bedside evaluation based on five physiological parameters: systolic blood pressure, pulse rate, respiratory rate, temperature and AVPU score. The ability of a modified EWS, including relative deviation from patients normal blood pressures and urine output, to identify patients at risk from deterioration and who would potentially benefit from more intensive monitoring from nursing and medical staff has been recently demonstrated. Use a random sample of 20 patients per month per unit (sample 5 patients per week). The review should be conducted for the previous three days of the patient s stay. Page 9

Percent of observations identified as at risk that have appropriate interventions undertaken in terms of their management as categorized by the Early Warning Score This measure will be phased in Numerator: the number of observations with appropriate interventions undertaken as indicated by their early warning score in the sample Denominator: the number of observations with an at risk early warning score Calculate the percent of observations identified as at risk that had appropriate interventions undertaken by dividing the numerator by the denominator and multiplying by 100 Inclusion Criterion: Patients admitted > 24 hours (excluding midwifery, pediatric /neonatal and non acute areas such as continuing care). Use the sample of 20 patients from process measure 1. Failure of clinical staff to respond to deterioration of respiratory or cerebral function and increase levels of medical intervention will put patients at risk of cardio-respiratory arrest. Inappropriate action in response to observed abnormal physiological and biochemical variables might lead to avoidable death. Suboptimal care prior to admission to a critical care unit can lead to increased mortality. Number of calls to the Outreach or Rapid Response Team This measure will be phased in The total number of calls placed each month to the Outreach or Rapid Response Team This measure is the total number of calls to the Outreach or Rapid Response Team each month. It is recommended that a process is established to record the calls registered each day. These can then be tallied each week and combined to produce an aggregate number for the month which can be entered into the Extranet. Percent compliance with Severe Sepsis 3- Hour Resuscitation Bundle This measure will be phased in Numerator: the number of patients with sepsis during the month receiving all components Denominator: the number of patients with sepsis reviewed during the month Calculate the percent compliance by dividing the numerator by the denominator and then multiplying the resulting proportion by 100 There should be no sampling for this measure. All patients with sepsis should be reviewed for compliance. All elements of the bundle must be met. If your percent compliance is low, measure each element of the bundle individually o The numerator would be the total number of eligible patients who received the element of the bundle o The denominator would be the number of eligible patients o The percentage would be calculated by dividing the numerator by the denominator and multiplying by 100 Page 10

Percent compliance with 6-Hour Septic Shock Bundle This measure will be phased in Numerator: the number of patients with septic shock during the month receiving all components at the appropriate time Denominator: the number of patients with septic shock reviewed during the month Calculate the percent compliance by dividing the numerator by the denominator and then multiplying the resulting proportion by 100 There should be no sampling for this measure. All patients with septic shock should be reviewed for compliance. All elements of the bundle must be met. If your percent compliance is low, measure each element of the bundle individually o The numerator would be the total number of eligible patients who received the element of the bundle o The denominator would be the number of eligible patients o The percentage would be calculated by dividing the numerator by the denominator and multiplying by 100 Page 11