CAUTI K-HEN Data Collection & Submission

1. CAUTIK-HEN Data Collection & Submission Dolores Hagan, RN BSN K-HEN Education and Data Manager August 2012

2. Objectives • Review reporting requirements • Review K-HEN recommended measures • Review the specifications for monitoring data (Inclusion and exclusion criteria) • Discuss requirements for baseline data • Define data entry and submission timeline • Identify measures that may be pulled from other systems where data is currently being entered

3. Reporting Requirements • For each topic area chosen, hospitals are required to submit data for at least • One process measure AND • One outcome measure • Hospitals are strongly encouraged to report on the K-HEN recommended measures • Additional outcome and/or process measures may be selected and reported as desired

4. K-HEN Recommended Measures • Purpose—standardize reporting on the same measures across the state for robust benchmarking capability • Measures selected based on polling data from the KHA Quality Conference in March 2012 • Have continued to evolve with your feedback (Keep it coming! )

5. HRET HEN Encyclopedia of Measures • Lists all measures available in the CDS • Defines the numerator and denominator for each measure • Provides a link to the source of the measure • http://www.k-hen.com/Portals/16/Documents/HRET_HEN_Encyclopedia_of_MeasuresV3.pdf

6. CAUTI: Outcome Measure • Preferred measure: #18, 19, 20 or 21 All tracked units, ICU, NICU or PICU CAUTI rate (device days denominator) **To capture unit specific measure, must build a custom measure.

7. CAUTI Outcome Measure Criteria • Numerator—Symptomatic UTIs that are catheter-associated (i.e. patient had an indwelling urinary catheter at the time of or within 48 hours before onset of the event) • Denominator—Number of urinary catheter days (All units tracked or specific unit) http://www.cdc.gov/nhsn/pdfs/pscManual/7pscCAUTIcurrent.pdf

8. CAUTI: Process Measure • Preferred Measure: #15 Urinary catheter removed on postoperative day 1 or day 2 (SCIP Inf-9) • Alternate Measure: #16 UTI Prevention Catheter Bundle Source: CMS SCIP Core Measures; IHI UTI Compliance Audit Tool

9. #15 CAUTI Criteria CMS Core Measure • Numerator—Number of surgical patients whose urinary catheter is removed on POD 1 or POD 2 with the day of surgery being day zero • Denominator—All selected surgical patients with a catheter in place postoperatively

10. #15 CAUTI Criteria • Inclusions • Qualified SCIP cases with an ICD-9 Code of selected surgeries as defined in the Specifications Manual for National Inpatient Quality Measures • Exclusions • < 18 years old • LOS > 120 or < 2 days postoperatively • Enrolled in clinical trials • Urological, gynecological or perineal procedure • ICD-9 principal procedure occurred prior to the date of admission • Discharge status expired • No urinary catheter postoperatively • ILP documentation of continued necessity • Urinary diversion or urethral catheter or intermittently catheterized prior to hospital arrival

11. Baseline Data • Only submitted one time • For all topic areas except Readmissions: • Baseline data is from 2011 prior toJanuary 1, 2012 • May be the entire calendar year of 2011 or any other period within the year (a month, a quarter, etc) • Enter your specific period beginning and ending dates • Readmission Baseline Data • Preferably CY 2011 • May use Jan – Jun 2012 if 2011 data is not available • If no baseline data is available, do not enter anything for baseline—begin with monitoring data

12. CAUTI Baseline Data Complete baseline data entry by August 31! • NHSN data will be extracted once rights are conferred • Data should be entered on a monthly basis as much as possible

13. CAUTI 2012 Monthly Data Entry Schedule *If data is available

14. Comprehensive Data System (CDS) • Link to HRET training webinar for CDS located on K-HEN website under Data Page • https://www.hretcds.org/Login.aspx • Data coordinator receives initial login and creates hospital’s users • At least two data administrators • As many data entry users as needed

15. Measure Selection • Review the K-HEN Recommended Measures and the HRET Encyclopedia of Measures • Determine which measures you will report Remember you MUST report on at least one process and one outcome measure per topic area selected

16. Measure Enrollment • Enroll in the measures that you are reporting • Select Admin  Measure Enrollment • Select the topic area • Select/deselect and save the measures that you will be reporting on • This will narrow your choices for data entry to only those selected • You may reselect those measures at a later time if desired

17. Data Collection & Entry • Review the numerator and denominator criteria for the measures selected • Collect and compile the data • Sign on to the CDS • Select Data Entry tab • Select the topic from the drop  Select Next • Find the appropriate measure  Select Enter Data

18. Baseline Data Entry • Defaults to the Baseline tab • Enter the Measurement start and end dates  Select ‘Add’ • Under ‘Data Entry’ column, Select ‘Go’ • Was data collected for this measurement period?  Select Yes or No • If No, enter reason (e.g. data not available) • If Yes, enter the numerator and denominator • Select Save or Submit • Save holds data in ‘temporary’ area and is not available for reporting within the CDS • Data may be edited by the hospital until it is submitted

19. Monitoring Data Entry • Select the Monitoring tab • Under the Data Entry column, Select ‘Go’ for the appropriate month • Was data collected for this measurement period?  Select Yes or No • If No, enter reason (e.g. data not available) • If Yes, enter the numerator and denominator • Select Save or Submit • ‘Save’ holds data in ‘temporary’ area and is available for reporting within the CDS • Data may be edited by the hospital until it is submitted

20. Data Tidbits • Each month should have data entered or a reason it was not collected • Additional training will be provided after data has been entered and reporting is available

21. Monthly Progress Report • Due to K-HEN by the 10th of each month • Use template provided • One report per topic area • Report template and sample complete report located on K-HEN website (www.k-hen.com) under Tools and Resources

22. Project Title: ______________________________ Date: _____________ Hospital Name: ____________________________ State: _____________ Self Assessment Score, 1-5 (see AHA/HRET Assessment Scale document) = <enter score here> Aim Statement Run Charts Lessons Learned (Enter summary here) Aim?: (Including your How Good and By When statement) (Make fonts large, title, labels, dates and notes very simple on graphs prior to shrinking graphs. Should be able to fit 6-8 readable graphs here. If no data are available for a particular measures either create “empty” run list the name of the measure(s) to be collected.) Why is this project important?: Recommendations and Next Steps • Enter summary here (what do you need from Executive Project Champion, Sponsor at this time to move project?) • Recommendations • Next steps for testing Changes being Tested, Implemented or Spread (For each listed change, indicate whether it is being tested (T), Implemented (I) or Spread (S)) Team Members (Name of Project Champion, Senior Leader Sponsor & all other names & roles) © 2012 Institute for Healthcare Improvement

24. Project Assessment Scale • http://www.k-hen.com/Portals/16/Documents/HRETHENProjectAssessmentScale.pdf

25. Homework • Set up CDS users for your site • Collect and enter baseline data by Aug 31 • Enter monitoring data for Jan - Jun 2012 as available and time permits • Enter monitoring data for Jul 2012 by Aug 31 • Complete July progress report by Aug 31 and email to info@k-hen.com (Due the 10th of the month thereafter)

26. Questions