Presentation - North Carolina Quality Center

NoCVA HAI Learning Network:
A Hospital Engagement Network
Project
February 13, 2013
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Some Background
• Partnership for Patients
• Hospital Engagement Networks
• Your hospital
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What’s It All About?
http://partnershipforpatients.cms.gov/aboutthe-partnership/what-is-the-partnershipabout/lpwhat-the-partnership-is-about.html

What does this mean?
• Your facility has pledged 40/20 to CMS
• CMS is not dictating how you do this.
• Role of HENs.
• HAI Learning Network is one of the NoCVA HEN models to
help achieve the goal of reducing HAI-related HACs by 40%.
• Even if you decide not to participate in this HEN project,
the commitment to reduce these HAIs by 40% still
exists.
• The pledge taken was to CMS, not to NoCVA HEN.
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So…
• Review this Pledge with your Leadership
• Participation in the Learning Network will provide important
information from experts and colleagues about HAI
prevention
• Essential to have specific, coordinated work going on in your
facility to put learning into practice
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HAI Learning Network Background
• All of the HAI HACs were “bundled” together under one “HAI
Learning Network” for 2013--CLABSI, CAUTI, VAE, and SSI
• Allows efficiencies for the participants and NoCVA Leadership
team.
• Allows participants to take advantage of multiple types of learning
opportunities
• SSI prevention content will continue in the Safe Surgery
Collaborative
o 2 groups will share SSI prevention offerings from both projects where
feasible.
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NoCVA HAI Partners
• Association for Professionals in Infection Control and
Epidemiology, NC and VA Chapters (APIC-NC and
APIC-VA)
• NC and VA Divisions of Public Health (NC and VA DPH)
• The Carolinas Center for Medical Excellence (CCME)
• Virginia Health Quality Center (VHQC)
• NC Statewide Program for Infection Control and
Epidemiology (NC SPICE)
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Leadership Team and Expert Panelists
Name Title Organization
Dr. Zack Moore Medical Epidemiologist NC DPH
Jayne Lee President, APIC-NC APIC-NC
Millie Lavaway 2012 President, APIC-VA APIC-VA
Andrea Alvarez HAI Program Coordinator VA DPH
Connie Jones HAI Program Coordinator NC DPH
Chrystal Adams Care Improvement Specialist CCME
Thelma Baker VP, Care Integration VHQC
Deb Smith Area Manager VHQC
Betsy Albee
2011 President, Current Board Member,
APIC-VA
APIC-VA
Kirk Huslage Associate Director, NC SPICE NC-SPICE
Dr. Carol Koeble Executive Director, NCQC NCQC
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So, what’s it all about?
• GOAL: Reduce SIR or rate by 40% by
December 31, 2013
• Four prevention focus areas: CLABSI, CAUTI,
VAE, and SSI
o Vertical prevention strategies
o Horizontal prevention strategies
o Sharing of innovative work
• Adaptive focus: CUSP
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Planned Activities
• Three regional CUSP Boot Camps (each facility is asked to
send at least one representative to one of the Boot Camps)
Two in NC
‣March 20 th in Winston-Salem, NC
‣April 11 th in Fayetteville/southeastern Piedmont, NC
One in Richmond, VA – April 16 th at VHHA
• Four-to-five webinars or networking conference calls
(depends on need and requests)
• One in-person conference at end of 2013
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Time Line
Timeframe
January and February 2013
March 20 (NC) and April 11 (NC) & 16 (VA)
Activity
Recruitment & Orientation webinars
Three regional CUSP Boot Camps
Action Period March – December 2013
Quarterly
May-November 2013
December 2013
January – June 2014
Data submission
Virtual learning sessions/networking
calls
In-person learning session
Sustainability monitoring
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What are “Vertical” and “Horizontal”
Prevention Strategies?
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CUSP: Comprehensive Unit-based
Safety Program
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http://www.ahrq.gov/cusptoolkit/

HAI Learning Network Metrics
HAI Outcome Measure Process Measure
CAUTI
CAUTI rate/SIR (NHSN definition) SCIP INF9*
CLABSI
CLABSI rate/SIR (NHSN
definition)
Daily review for necessity of central
line. (Report through QDS only)
VAE or VAP
VAE or VAP rate (NHSN
definition)
Daily assessment for readiness to
wean. (Report through QDS only)
SSI
COLO and HYST rate/SIR
(NHSN definition)
SCIP measures*
*No additional data collection required. Data obtained from SCIP data already submitted by your facility to CMS.
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Measurement
• May report via NHSN or QDS (Quality Data System)
• Request is for all metrics unless service does not apply to
your facility.
o You may concentrate prevention efforts on one or more of
the HAIs.
o Data submission on all is requested unless not
possible/feasible: E.g. your risk assessment has identified
CAUTI as the HAI you most need to work on and you do
extremely low volumes of surgical procedures (

Data Timeframe Measure Due Date* Where to Submit
Baseline Data:
Oct-Dec’12
Jan-Mar’13
Apr-Jun’13
CAUTI, CLABSI, COLO &
HYST, VAP/VAE
CAUTI, CLABSI, COLO &
HYST, VAP/VAE
CAUTI, CLABSI, COLO &
HYST, VAP/VAE
March 5, 2013
June 5, 2013
September 6,
2013
NHSN preferred for outcome
measures. QDS may be used
instead for outcome measures.
QDS is to be used for process
measures that are not SCIP
measures. (All of the SCIP
measures will be pulled from
the state QIOs.)
Jul-Sep’13
Oct-Dec’13
Jan-Mar’14
Apr-Jun’14
CAUTI, CLABSI, COLO &
HYST, VAP/VAE
CAUTI, CLABSI, COLO &
HYST, VAP/VAE
CAUTI, CLABSI, COLO &
HYST, VAP/VAE
CAUTI, CLABSI, COLO &
HYST, VAP/VAE
December 6,
2013
March 7, 2014
June 2, 2014
September 5,
2014
*If you follow your state’s DPH data submission timeframe, you will be compliant with this one.
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Hospital Commitment
• Set goal to reduce HAIs by 40% by 12/31/13 (or to zero
if rates already very low) compared to 2010 data.
• Participate in Learning Network Activities:
o Learning sessions
o Implementation of HAI prevention strategies
o Share learning from sessions internally at your facility
o Share what your facility is doing to prevent HAIs with other
LN participants
• Actively work on HAI prevention at your facility
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NoCVA Leadership Commitment
Provide:
• Expert Faculty
o to share knowledge and experience during planned learning
sessions
• Vertical and horizontal HAI prevention educational
content
o virtual and in-person learning sessions (technical component)
• Education and training in adaptive strategies such as the
CUSP model
• Opportunities to network and share among participants
• Routine Feedback on Learning Network measures
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How do we sign up?
• If not already done, let your primary NoCVA HEN hospital
contact know that you want to participate in this LN. (That
person is coordinating HEN project participation and getting
the data use agreement signed.)
• Select a project Primary Contact, someone who:
o Knows what’s going on with HAI projects in your facility
o Can ensure metrics are submitted on time and appropriately
o Is willing to push LN information out to facility stakeholders
o Will act as the key “go-to” person for NoCVA staff about this
project
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Frequently Asked Questions
1. Do we have to enroll a specific unit and submit teammember
names?
o No – but remember, you do need active HAI prevention work going
on in your hospital!
o Anyone you wish to be on the LN’s listserv would need to have their
information submitted
o We do ask that at least one person in the organization be identified
as a Primary Contact who has knowledge of the work being done to
prevent HAIs. (This does NOT have to be the IP.)
2. Do we have to take a patient safety survey for
participation?
o No
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FAQs - continued
3. Is there a limit to the number of people we can send to the
in-person CUSP Boot Camps or in-person conference?
o No, although a limit may need to be set if sessions become full
quickly, so register early.
4. Is there a cost to us to participate in the HAI Learning
Network?
o The only cost to your organization is limited to travel expenses
attendees from your facility will incur as a result of participating in the
in-person learning sessions such as mileage, meals and overnight
stay if necessary.
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FAQs…
5. What if I’m already participating in my QIO
collaborative for one of these HAIs? (CCME or VHQC)
Because both of the states’ QIOs are partners in this LN, we
are coordinating activities to ensure participants have access
to all LN and QIO offerings when feasible. Even if you are
already enrolled in one of the QIO collaboratives, we do ask
you sign up for the LN and provide to us a Primary Contact
person to ensure you get all of the notifications from the LN
and because we have to track all participating hospitals as
part of our contract agreement with CMS.
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One more FAQ…
6. I’m concerned about sharing my hospital’s data
transparently within the LN. Our denominators are so
small that even one HAI makes us look terrible when
being compared with other hospitals. How will this be
addressed?
We will share raw data along with rate data when hospital rate data are
presented. This will help everyone recognize that high rates may not
mean poor performance. In addition, as all hospitals are approaching
very, very low incidences of HAIs and zero is the ultimate goal, raw
data are becoming more important to look at and share.
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Other Questions?
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So, what next?
• If you have not already signed up for the HAI Learning
Network and wish to, let us know.
• Once signed up, provide to us the name and contact
information for your Primary Contact.
• Register for one of the CUSP Boot Camps at
https://www.ncha.org/education/register-for-a-meeting
(Scroll down the page – title is “NoCVA HAI LN CUSP Boot
Camp.” All three sessions are listed, so choose the date
and location you want and click on it.)
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HAI Learning Network Contact
Information
Name Title Phone Email
Laini Jarrett-
Echols
Project Manager,
NCQC
919-677-4123 Ljarrettechols@ncha.org
Shelby Lassiter PI Specialist, NCQC 919-677-4119 slassiter@ncha.org
Jan Mangun
Executive Director,
Quality and Patient
Safety, VHHA
804-965-1202 jmangun@vhha.com
Sarah Roberts Project Coordinator 919-677-4139 sroberts@ncha.org
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