On the CUSP: Stop CAUTI Cohort 8 Learning Session 1

1. On the CUSP: Stop CAUTICohort 8 Learning Session 1 CAUTI Project Data: How to Get Started Barbara Meyer Lucas, MD, MHSA, CPPS Project Consultant Michigan Health & Hospital Association (MHA) Keystone Center for Patient Safety & Quality

2. LEARNING OBJECTIVES: • Know Why Data is Crucial to the Project • Know the Project’s Data Elements: • What Data Do We Collect? • When Is It Due? • What Infrastructure Do Teams Need to Accomplish This?

3. Why is Data Crucial to the Project? GOALS for the CAUTI COLLABORATIVE: Improve the culture of safety on your unit via implementation of CUSP (Comprehensive Unit-Based Safety Program) Reduce your unit’s CAUTI rate by 25%

4. Why is Data Crucial to the Project? Project’s data elements will help you: Measure progress of CAUTI reduction Track adoption of technical work and CUSP interventions Identify barriers to teams’ progress Stay on course to achieve BOTH project goals

5. CAUTI PROJECT DATA ELEMENTS: • Background/Cultural Data: • Readiness Assessment • HSOPS: Baseline and Follow-up • Ongoing Outcome Data Submission • Outcome data • Process data(optional) • Team Checkup Tool

6. BACKGROUND/CULTURAL DATA: Readiness Assessment • PURPOSE: Tells us about your unit: • size, type, patient demographics • prior involvement in any CAUTI prevention and/or CUSP activities • prior patient safety/performance improvement activities

7. BACKGROUND/CULTURAL DATA: Readiness Assessment Unit/Team Lead Responsibilities: • Completed ONCE at the start of the project • Done via Survey Monkey • MHA will email the survey link to each designated unit lead prior to May 12 when survey opens • Completed by only ONE person per unit • Due by May 26, 2014

8. BACKGROUND/CULTURAL DATA: HSOPS • PURPOSE:Standardized measure of safety culture for individual patient care unit (NOT hospital-wide) • LOGISTICS: • Done twice: at the beginning/after the project intervention • Need at least 60% response rate

9. BACKGROUND/CULTURAL DATA: HSOPS Infrastructure Needed: • Each unit needs a survey coordinator who • registers their unit • estimates # of staff who will take survey • educates staff about the survey process • ensures 60% survey response rate

10. BACKGROUND/CULTURAL DATA: HSOPS Unit/Team Responsibilities: • Choose a survey coordinator for your team • Coordinator and Team Lead MUST listen to the HSOPS training webinar • choose one date: May 20 or May 22 (same call on both dates) • Manage the survey process

11. BACKGROUND/CULTURAL DATA: HSOPS • Dates to remember: • HSOPS Training Webinars:May 20 and 22 • same content repeated • Baseline HSOPS: registration starts May 26 • survey runs June 9 – July 4, 2014 • Follow-up HSOPS: registration starts May 18, 2015 • survey runs June 1 – June 26, 2015

12. BACKGROUND/CULTURAL DATA: Key Resources • MHA: • Readiness Assessment and HSOPS: Lucy Koivisto (lkoivisto@mha.org) • National Project Website: • www.onthecuspstophai.org

13. CAUTI PROJECT DATA ELEMENTS: • Background/Cultural Data: • Readiness Assessment • HSOPS: Baseline and Follow-up • Ongoing Outcome Data Submission • Outcome data • Process data (optional) • Team Checkup Tool

14. ONGOING DATA COLLECTION:Outcome and Process Data OUTCOME DATA: What impact have we made on our 2 project goals: 1) reducing the CAUTI rate by 25% and 2) improving our unit’s culture of safety PROCESS DATA:Are we changing our daily work activities regarding catheters in a way that reduces the risk of infection (technical work) and makes care safer (culture change/CUSP)?

15. CAUTI OUTCOME DATA: What Do We Collect? For the entire month (not just M-F) each enrolled unit must collect and submit: Total # of patient days for that unit Total # of indwelling urinary catheter days for that unit Total # of CAUTIs for that month Result: CAUTI Rates Catheter Prevalence

16. CAUTI OUTCOME DATA: What Infrastructure Do Teams Need? • Someone to collect the data • should be knowledgeable about NHSN criteria • should resolve any “questionable CAUTI” issues before entering data • Good resource: ICP

17. CAUTI OUTCOME DATA: What Infrastructure Do Teams Need? • Someone to enter the data • either into NHSN or Care Counts (if state level data will be imported from NHSN into Care Counts) • must do Care Counts training (4/30 or 5/7, same call offered twice)

18. CAUTI OUTCOME DATA: When is it due?Starts in MAY, with Three Phases BASELINE (Monthly submission) May, June, July 2014 IMPLEMENTATION (Monthly submission) August and September 2014 SUSTAINABILITY: (1 month per quarter) December 2014; March and June 2015 Note: all data is due by the end of the following month

19. OUTCOME DATA: How Do I Enter It? WHERE? Care Counts HOW? • Manual Entry OR • Data transfer from NHSN (teams need to confer rights to state lead to do this)

20. CAUTI OUTCOME DATA: Unit/Team Lead Responsibilities: Make sure units have a leader for BOTH outcome data collection and data entry Decide: will your team confer rights to your state lead to import data from NHSN to Care Counts, OR will you enter the data yourself? Get comfortable with Care Counts yourself!

21. CAUTI OUTCOME DATA: • Dates to remember: Care Counts Training: • Webinar format April 30 and May 7 • Same call, choose one day to attend Every team lead and team data entry person are expected to listen to call

22. CAUTI OUTCOME DATA:Key Resources: • MHA: • Understanding Data Elements: Your assigned MHA coach/Extended Faculty • Care Counts: Lucy Koivisto(lkoivisto@mha.org) • National Project Website: www.onthecuspstophai.org

23. PROCESS DATA: What Do We Collect?(note: submission is optional) Collect these elements DAILY, following the submission schedule: # of patients on the unit that day # of catheterized patients on the unit that day Main reason why patient has a catheter TODAY Where the catheter was inserted (on the floor, off the floor, unknown) Result: Catheter Appropriateness Info

24. CAUTI PROCESS DATA: What Infrastructure Do Teams Need? • Have your team in place • Crucial: physician leader, nurse leader, frontline care provider, infection control practitioner • Be conversant with HICPAC guidelines as to appropriate indications for catheters

25. CAUTI PROCESS DATA: What Infrastructure Do Teams Need? • Need a rounding process (not record review) • IDEAL: piggyback on existing unit rounds • use the recommended audit tool • Need a designated point person to record data/contact physicians for orders to remove catheters

26. CAUTI PROCESS DATA: What Infrastructure Do Teams Need? EXPECTATION: The rounding process goes on daily during the project, regardless of whether data is to be submitted on that day! Remember: This rounding process IS the intervention!!!

27. CAUTI PROCESS DATA: What Infrastructure Do Teams Need? • Need someone to enter the data into Care Counts • Must have Care Counts training • Data should be entered ASAP • Ideally enter the same day team rounds • Teams should be talking about their findings

28. Process Data Collection Tool

29. CAUTI PROCESS DATA Unit/Team Lead Responsibilities: Make sure your unit has a rounding process ready to go for daily catheter appropriateness Monitor closely! Is your team rounding? Are they entering data into Care Counts ASAP? What are they learning about catheter usage? Are practices changing as a result?

30. CAUTI PROCESS DATA: When is it due?Starts in JULY, with Three Phases BASELINE (Submitted M-F, for 3 Weeks) July, 2014 IMPLEMENTATION (specific dates, per schedule) August and September 2014 SUSTAINABILITY: (M-F one week per qtr) December 2014; March and June 2015 Note: all data is due the month it is collected

31. CAUTI PROCESS DATA:Key Resources: • MHA: • Understanding HICPAC/Rounding: Your assigned MHA coach/Extended Faculty • Care Counts: Lucy Koivisto (lkoivisto@mha.org) • National Project Website: www.onthecuspstophai.org

32. ONGOING DATA COLLECTION:Quarterly Team Checkup Tool (TCT) What it assesses: Implementation of CUSP and CAUTI reduction activities Team functioning Barriers to project progress

33. TCT DATA: How Do I Enter It? Recommended Way to Complete it: Team Leader prints copies of the TCT (available on the national project website) Team meets to discuss and reach consensus on answers One person enters the team’s consensus answers into Care Counts

34. TEAM CHECKUP TOOL: When Is it Due? • Due Quarterly • Reflects the team’s work for the previous 3 months • Schedule: first TCT due by August 31 • reflects work of team during May, June, and July • then due once every 3 months: November 2014; February and May 2015

35. TCT DATA Unit/Team Lead Responsibilities: Print out the tool from the website quarterly Meet with your team to reach consensus on the answers, based on the work you did over the previous 3 months Submit on time to Care Counts

36. TCT DATA:Key Resources • MHA: • Understanding the Tool: Your assigned MHA coach/Extended Faculty • Care Counts: Lucy Koivisto(lkoivisto@mha.org) • National Project Website: www.onthecuspstophai.org

37. SUMMARY: Cohort 8 Data Submission Schedule

38. VALUE OF CAUTI DATA:Helping Your Team Track Progress STANDARD REPORT SET TO RUN: Review these 3 Categories Monthly: Data Submission Outcome Data Process Data

39. STANDARD REPORTS TO RUN(from Care Counts) Data Submission: Run 3 Reports • Outcome Data Submission Report (1 report) • shows your unit’s submitted data, by project phase • Process Data Submission Reports (2 reports) If submitted: • shows submission rates by project phase, and for each day of data collection

40. STANDARD REPORTS TO RUN(from Care Counts) Outcome Data: Run 3 Reports • CAUTI Rate Reports (2 reports) • by Catheter Days (# CAUTI’s/1000 catheter days) • by Patient Days (#CAUTI’s/10,000 patient days) • shows your unit’s infection rates • Catheter Prevalence Report (1 report) • shows the percent of patients on your unit with a catheter for that month

41. STANDARD REPORTS TO RUN(from Care Counts) Process Data: Run 2 Reports If submitted: • Catheter Appropriateness Reports (2 reports) • Catheter Appropriateness • shows what % of catheterized patients had at least one appropriate reason for the catheter • Catheter Indicator Breakout • shows what the reasons were

42. TAKE HOME MESSAGES: What Data Do We Collect? Preliminary Work: Readiness Assessment /HSOPS During Project: Outcome Measures: (Collect/Submit Monthly) CAUTI Rates and Prevalence Process Measures: (Optional; submit per schedule) Catheter Appropriateness Team Checkup Tool (TCT): Submit every 3 months Follow-up: HSOPS

43. TAKE HOME MESSAGES:When is Data Due? Outcome Measures: Collection starts: MAY 2014, then per schedule Due: by end of following month Process Measures: Collection starts: JULY 2014, then per schedule Due: enter in real time, ASAP TCT: Completion starts: AUGUST 2014, then per schedule Due: by end of that month

44. TAKE HOME MESSAGES: WHY IS DATA IMPORTANT TO THE PROJECT? • Data submission tracking: • ensures dataset is robust and findings are reliable • Process and Outcome Measures: • provide continuous monitoring of whether CAUTI rates and catheter prevalence are decreasing • focus attention on which patients inappropriately have catheters, so education and processes can be implemented to reduce unnecessary catheter use and infection risk

45. TAKE HOME MESSAGES: WHY IS DATA IMPORTANT TO THE PROJECT? • Quarterly Team Checkup Tool: • monitors teams’ implementation of recommended: 1) CUSP activities 2) CAUTI reduction activities • identifies barriers to team progress • HSOPS: • assesses units’ culture of safety before and after the project intervention

46. TAKE HOME MESSAGES:Anticipatory Guidance • Data Collection Process: • is front-end loaded, but manageable • is the primary way to effect change in the use of inappropriate catheters • Remember: Rounding for Catheter Prevalence and Appropriateness IS the intervention!

47. TAKE HOME MESSAGE: The work that each of you does to follow the catheter recommendations for EVERY patient, EVERY time, helps us reduce the risk of CAUTIs. Thank you for all that you do to make care safer for our patients.