5M Lives Campaign Grantee Call 112807

1
5M Lives Campaign Grantee Call11-28-07

• CFMC
• Cari Fouts
• Richard Delaney

2
Launch Event

• Thank you for participating!
• Presentations available electronically
• Many of you set ambitious goals and small tests
  of change!

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Todays Objectives

• Discuss where your are in implementation stages
• Recap Model For Improvement
• Discuss grantee data collection
• Execution assignment for next call
• Communications resources internally/externally

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Pressure Ulcers

• At what level of implementation are you regarding
  Pressure Ulcer prevention?
• Haven't started yet 12.2
• In the planning stages 58.5
• Pilot testing 0.0
• Implemented in a few departments 9.8
• Fully implemented house-wide 19.5

5
MRSA Prevention

• At what level of implementation are you regarding
  MRSA prevention?
• Haven't started yet 17.1
• In the planning stages 39.0
• Pilot testing 9.8
• Implemented in a few departments 19.5
• Fully implemented house-wide 17.1

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IHI Model for Improvement

• Answers 3 questions
• Aim What are we trying to accomplish? (what, by
  how much, where, by when?)
• Measures How will we know that a change is an
  improvement?
• Change What changes can we make that will result
  in improvement? (multiple PDSA cycles)

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SMALL Tests of Change!

• A test should be small scale and answer a
  specific question
• Will this pressure ulcer admission assessment
  form be a user friendly tool for documentation?
• Are the hand hygiene gel dispensers located in
  places that are consistent and readily visible to
  staff?
• A test should have a theory and a prediction

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Why test? Why not jump in with house-wide
process?

• Increases degree of belief.
• Documents expectations.
• Evaluates costs and side-effects.
• Explores theories and predictions.
• Tests ideas under different conditions.
• Learn and adapt on a small scale.

Fran Griffin, IHI Leading and Implementing Safety
Strategies Role of Managers, 2007
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Test of Oneness

• One unit
• One nurse/physician
• One patient
• THEN, use 135ALL rule

Fran Griffin, IHI Leading and Implementing Safety
Strategies Role of Managers, 2007
10
Measuring change

• How will you know you are making a difference?
• Process goals vs. outcomes goals
• Process must be reliable and then outcomes follow

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Statewide Goals

• Reduce MRSA infections by 30
• Reduce Pressure Ulcers by 60

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Measuring our Effectiveness as a State

• Process Measures
• Percent of at risk patients receiving full
  pressure ulcer preventive care
• Hand Hygiene compliance
• Outcomes Measures
• Pressure Ulcers per 1000 patient days
• MRSA infections per 1000 patient days

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Pressure Ulcer Bundle

• 1. Conduct a Pressure Ulcer Admission Assessment
  for All Patients
• 2. Reassess Risk for All Patients Daily
• FOR HIGH RISK PATIENTS (from above)
• 3. Inspect Skin Daily
• 4. Manage Moisture
• 5. Optimize Nutrition and Hydration
• 6. Minimize Pressure

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Percent at risk PU patients receiving complete
care

• Definition The percentage of patients identified
  as at risk for pressure ulcers for whom all
  components of proper pressure ulcer care were
  performed and documented in the calendar day
  prior to review. If a component of care is not
  applied due to a documented contraindication,
  count it as appropriately performed for the
  purposes of this measure. Proper pressure ulcer
  care includes the following five components
• Daily inspection of skin for pressure ulcers
• Proper management of moisture, including both
  cleaning and moisturizing skin
• Optimization of nutrition
• Repositioning every two hours
• Use of pressure-relieving surfaces

IHI Measurement Forms, Pressure Ulcers
15
PU Compliance Calculation Details

• Numerator Definition Number of patients
  identified as at risk for pressure ulcers for
  whom all components of proper pressure ulcer care
  were performed and documented in the calendar day
  prior to review.
• Numerator Exclusions None 
• Denominator Definition Total number of patients
  identified as being at risk for pressure ulcers
• Denominator Exclusions Patients admitted on
  current day or prior calendar day
• Measurement Period Length Weekly
• Calculate as (numerator/denominator) x 100 as
  percent

IHI Measurement Forms, Pressure Ulcers
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Tips for PU Compliance Measurement

• All-or-none measure, but if contraindication is
  properly documented, credit is given
• This does NOT measure assessment effectiveness,
  which you may want to measure separately
• Use a standardized form in patient chart to
  collect data

IHI Measurement Forms, Pressure Ulcers
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Sampling Plan

• Conduct the sample one day per week, choosing the
  day of the review at random.
• Review as few as 10 patients per week
• Choose patient records randomly from identified
  at-risk patients. If there are insufficient
  admissions on the given day, incorporate patient
  records from the previous day in your sample.
• As your team becomes more comfortable with the
  reviewing process, you may increase the number of
  charts reviewed.
• If you are beginning this intervention within a
  pilot unit or units, limit your initial
  measurement to only those units. As you spread
  the implementation, expand your measurement
  accordingly.

IHI Measurement Forms, Pressure Ulcers
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Pressure Ulcer Incidence Per 1000 Patient Days

• Numerator Definition Number of pressure ulcers
  developed in hospital
• Numerator Exclusions None
• Denominator Definition Total number of patient
  days
• Denominator Exclusions None
• Measurement Period Length Monthly
• Definition of Terms You define
• Calculate as (numerator / denominator) x 1000
  as rate

IHI Measurement Forms, Pressure Ulcers
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PU Incidence Collection Strategy

• There are two recommended strategies for
  collecting data used in this measure
• Via a form which includes documentation of new
  pressure ulcers in the chart.
• A variant of this method is to create forms that
  document the development of a new pressure ulcer,
  which nurses should submit to the units charge
  nurseor to some central body.
• Include only patients with completed stays in
  the data collection for this measure.

IHI Measurement Forms, Pressure Ulcers
20
PU Incidence Sampling Strategy

• Limit your measurement activity in this measure
  to only patients that have been identified as at
  risk, either at admission or during their stay.
• If you are beginning this intervention within a
  pilot unit or units, limit your initial
  measurement to only those units.
• Beyond limiting your sample to at-risk patients
  and patient in your pilot unit(s) as described
  above, you should try not to further reduce your
  sample size, as incidence rates of pressure ulcer
  are typically low.

IHI Measurement Forms, Pressure Ulcers
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Hand Hygiene Compliance

• Numerator Definition Number of patient
  encounters directly observed in which a health
  care worker performed all components of hand
  hygiene and glove use correctly in the calendar
  month
• Numerator Exclusions None
• Denominator Definition Total number of patient
  encounters observed in the calendar month
• Denominator Exclusions None
• Measurement Period Length Monthly
• Calculate as (numerator / denominator) x 100 as
  a percent.

IHI Measurement Forms, MRSA
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Hand Hygiene Complete Compliance
Gloves should be worn for all types of contact
if the patient is on isolation precautions that
require the use of gloves for contact with the
patient and the environment, or if there is a
unit-based procedure for universal gloving
(wearing gloves for contact with all patients and
their immediate environment).
23
Hand Hygiene Collection Strategy

• Compliance is monitored with direct observation
  by a trained observer using a standardized
  procedure and form.
• Observation periods should be 20-30 minutes
  (repeated if necessary) so that approximately
  25-30 patient encounters are observed.
• Observers should be as unobtrusive as possible,
  but do not need to be hidden from health care
  workers on the unit.

IHI Measurement Forms, MRSA
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Hand Hygiene Sampling Strategy

• Schedule set time periods in advance, distributed
  equally across shifts, days, and units (if
  measuring on more than one unit).
• If you are beginning this intervention within a
  pilot unit or units, limit your initial
  measurement to only those units.

IHI Measurement Forms, MRSA
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MRSA Bloodstream Infections per 1000 Patient Days

• Numerator Definition Number of patients with
  MRSA bloodstream infection during the calendar
  month
• Numerator Exclusions Same as denominator
  exclusions
• Denominator Definition Total number of hospital
  patient days for the calendar month after
  subtracting
• Patient hospital days after the onset of an MRSA
  bloodstream infection (e.g., patient is admitted
  and has a 10-day length of stay MRSA bloodstream
  infection identified from culture collected on
  day 4 hospital days 4 through 10 are subtracted
  as this patient is no longer at risk)
• Denominator Exclusions
• Patients with a length of stay of 2 days or less
• Patients with MRSA bloodstream infection
  identified from blood cultures collected in the
  first 2 days of the patients stay
• Measurement Period Length Monthly
• Calculate as (numerator / denominator) x 1000
  as a rate

IHI Measurement Forms, MRSA
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MRSA Definition of Terms

• MRSA bloodstream infection CDC definition for
  laboratory-confirmed bloodstream infection (LCBI)
  with MRSA as the organism identified in blood
  culture (SOURCE The National Healthcare Safety
  Network (NHSN) User Manual, page 6.

IHI Measurement Forms, MRSA
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MRSA Sampling Strategy

• If you are beginning this intervention within a
  pilot unit or units, limit your initial
  measurement to only those units. As you spread
  the implementation, expand your measurement
  accordingly.
• Stay consistent with definitions throughout the
  submission period

IHI Measurement Forms, MRSA
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DATA

• Start collecting pilot unit (or more) data in
  December for Campaign period (next 18 months)
• Next data submission period is January 2008, all
  mortality/profile data updated through November
  2007
• Enter intervention level data from December 07
  March 08 during April 08 submission period

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Without Data

• Reduce harm?

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Necessary Data

• Outcome data
• Incidence or prevalence of pressure ulcers
• During stay?
• Overall?
• Incidence of MRSA
• Health care acquired?
• Community acquired?

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Compared to Baseline

• Data not going to be used to compare hospitals
• Data collection on sample
• Service line
• Specific time

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Data Collection - MRSA

• Billing codes
• V090 as secondary diagnosis
• Approximately 2038 cases in Colorado Medicare
  Admissions in 2006
• 0.93 of all Medicare Admissions

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Data Collection - MRSA

• Denver hospitals and labs participate in the CDC
  Active Bacterial Core Surveillance program
• Use lab reports from hospitals and labs to
  identify cases
• Potential to share with 5M Lives?

34
Data Collection - MRSA

• JAMA article October 17, 2007
• 480 cases in Denver metropolitan area in 2005
• Used CDC data to predict MRSA cases
• 31.8 cases per 100,000 in US
• Approximately 1600 cases in Colorado in 2007

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Data Collection Pressure Ulcers

• Billing codes
• 707.xx as secondary diagnosis
• Approximately 7252 cases in Colorado Medicare
  Admissions in 2006
• 3.33 of all Medicare Admissions

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Concurrent Data Collection Options

• Pressure Ulcer forms
• Examples
• MRSA lab reports

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Small test of change can be done today

• Test of oneness
• Take action today
• Test on the next patient that walks in the door

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By next Friday, December 7th A Plan for PU and
MRSA

• Identify a high level aim
• Identify one high risk unit to begin work on
• PU ICU, Med/Surg, Rehab, transitional care unit,
  etc.
• MRSA ICU, NICU, Oncology, etc.
• Identify AT LEAST one small test of change (PDSA)
• Send to Rebecca Fox (rfox_at_cfmc.org)

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By Next Call January 9th 10-11am MT

• Try at least one small test of change for MRSA
  and Pressure Ulcers, and be prepared to share
  what you learned!

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Recap

• Start small, find a method for data collection
  that works for your setting
• By Friday the 7th (send to rfox_at_cfmc.org)
• Identify aim for MRSA and Pressure Ulcers
• Identify high risk pilot unit for MRSA/PU
• Identify at least one small test of change for
  MRSA/PU
• By Wednesday, January 9th
• Come to call prepared to learn from others and
  share the results of your small tests!

41
Questions?

• Cari Fouts, cfouts_at_cfmc.org
• Hilarie Olson, holson_at_cfmc.org
• Richard Delaney, rdelaney_at_cfmc.org
• Rebecca Fox, rfox_at_cfmc.org

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SE2 Role, Communications

• Strategic communications planning
• Technical assistance
• Advice/ideas
• Tool-box of materials

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SE2 Role

• SE2 will help hospitals develop
• A communications plan including activities to
  help spread, sustain and support campaign efforts
  internally and externally.
• An outreach plan to inform patients and families
  about your hospitals efforts to improve the
  safety of care.

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5M Lives Communications

• Sample of Internal Communications Activities
• Modify template article for employee newsletter
• Post campaign flyers in areas frequented by
  hospital employees
• Talk about your hospitals involvement in the
  campaign at employee and physician meetings

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5M Lives Communications

• Sample of External Communications Activities
• Modify and send template press release to local
  media
• Provide information sheets for patients and
  families in hospital waiting rooms and pharmacies
• Modify template newsletter article for public
  newsletter

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5M Lives Communications

• Website
• www.Colorado5MillionLives.org
• (Will be updated with materials and information
  throughout the campaign.)

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Questions?

• Olivia Gallegos
• Campaign Communications Coordinator
• SE2
• 907 Acoma St. Denver, CO 80204
• 303-892-9100 x 19
• Olivia_at_PublicPersuasion.com