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