CCQ Creating a Culture of Quality CREATING A CULTURE OF QUALITY: Developing the Infrastructure to Meet Quality Improvement Requirements Collaboration Reducing HAI’s Denise VanValkenburgh, RN, BA Liberty dialysis 3/16/2011 A renal community collaboration Call to Action! • Infections are 2nd leading cause of death and accounted for 14% of deaths in 2004 • Hospitalizations for infections increased 34% between 1993 and 2006 • Actual # related to BSI in HD pts is not known but estimated to be 50,000 per year • BSIs resulted in 103 hospital admissions /1,000 patient-years • USRDS documented 105% increase in total admission for VA infections from 1993-2006 CCQ 3/16/2011 A renal community collaboration Creating a Culture of Quality Brief History • 2002: MMWR: Guidelines for Prevention of IV catheter-related infections • 2005: CDC- NHSN (voluntary) • 2006: NKF- DOQI Guidelines • 2008: HHS/GAO released HCAI in Hospital • 2009: HHS Steering Committee for the Prevention of HAI- Second Phase (2009) expanded to include ESRD facilities • 2010: Patient Protection and Affordable Care Act • 2010: Colorado Dialysis units began reporting DRI to the NHSN; with data being publically reported • 2011: Network 3 clinics will being reporting DRI to NHSN • 2011: MMWR: Vital Signs: Central Line- ABSI- US 2001, 2008, 2009 CCQ 3/16/2011 A renal community collaboration Creating a Culture of Quality Liberty Initiatives • Collect Surveillance Data on a monthly basis (QAPI at a Glance) • Analyze Data and stratify clinics into 4 quartiles • Review Data with the Medical Advisory Board (MAB) and develop educational tools to educate professional staff – Work with clinics in the top quartile to identify “best demonstrated practices” – Work with clinics in the lower quartile to improve performance • Collaborate with Oversight Agencies (CMS/Networks) to improve facility level performance CCQ 3/16/2011 A renal community collaboration Creating a Culture of Quality Next Steps? • Educate community on ‘new’ terminology – HAI -CLABSIs -LAI -AAB • Standardize data analyzes/comparison – – – – USRDs reports ‘patient-years’ NHSN reports ‘patient-months’ MMWR refers to ‘patient-days’ Literature reports data in multiple ways • Coordinate facility level activity with Corporate offices • Sensitivity to time commitment of local data collection efforts CCQ 3/16/2011 A renal community collaboration Creating a Culture of Quality