Aligning Forces for Quality: Transforming Care at the Bedside Data Template Training

1. Aligning Forces for Quality: Transforming Care at the BedsideData Template Training Kathy Vezina

2. Overview of TCAB Required Measures Patient falls Falls with harm Pressure ulcer prevalence Potential Voluntary Measure & High Leverage Changes

3. Required Measure: Patient Falls • Fall is defined as an unplanned descent to the floor. • Numerator: Number of inpatient falls on the unit. • Denominator: Total number of inpatient days on unit.

4. Required Measure: Falls with Harm • Falls with harm is defined as minor (results in application of dressing, ice, cleaning of a wound, limb elevation, or topical medication), moderate (results in suturing, steri-strips, fracture, or splinting), major (surgery, casting, or traction), or death (as a result of the fall). • Numerator: Two separate numerators are to be reported separately: Number of inpatient falls and number of inpatient falls with injuries on the unit. • Denominator: Total number of inpatient days on unit.

5. Required Measure:Pressure Ulcer Prevalence • Hospital Acquired Pressure Ulcer (Nosocomial) is defined as new ulcer(s) developed after admission to a facility. All pressure ulcers not meeting the community-acquired criteria should be designated as hospital-acquired pressure ulcers. Pressure ulcer is defined as localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. • Numerator: Number of pressure ulcers developed using the National Advisory Panel (NPUAP)-Stage II or greater (II-IV+ eschar) for hospital-acquired pressure ulcers. • Denominator: Total number of inpatient days on unit.

6. Required Measures:Frequency and Reporting • Frequency: Monthly on the TCAB unit. • Reporting: The data collection spreadsheet provided to the unit will have cells to enter inpatient days on the unit, number of falls, number of falls with harm, and pressure ulcers. The rate will be calculated in the spreadsheet.

7. Race, ethnicity and language categories Race • Black • White • Asian • American Indian/Alaska Native • Native Hawaiian/ Pacific Islander • Multiracial* • Declined* • Unavailable* Ethnicity • Hispanic • Not Hispanic • Declined* • Unavailable* Language • English • Spanish • Other • Declined • Unavailable *This designation indicates a modification to the OMB R/E categories

8. Race definitions Black or African American: Person having origins in any of the black racial groups of Africa; include terms such as “Haitian,” “Dominican,” or “Somali.” White: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. Asian: Person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. American Indian or Alaska Native: Person having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment. Native Hawaiian or Other Pacific Islander: Person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. Multiracial*: A person having more than one or a combination of the above origins. Declined*: Patient is unwilling to choose a race category or cannot identify him/herself with one of the listed races. Unavailable*: Patient is physically unable to respond. *This designation indicates a modification to the OMB R/E categories Source: HRET Toolkit, http://www.hretdisparities.org/ accessed on Sept 16, 2009

9. Ethnicity definitions Hispanic or Latino: Person of Cuban, Mexican, Puerto Rican, South or Central American decent, regardless of race. Non-Hispanic or Latino: Person not of Hispanic or Latino ethnicity. Declined*: Patient is unwilling to provide an answer to the ethnicity question or cannot identify him/herself as Hispanic or Not Hispanic. Unavailable*: Patient is physically unable to respond. *This designation indicates a modification to the OMB R/E categories Source: HRET Toolkit, http://www.hretdisparities.org/ accessed on Sept 16, 2009

10. Language Definitions English: English is the language identified by the patient for speaking to health care providers or reading health care information. Spanish: Spanish is the language identified by the patient for speaking to health care providers or reading health care information. Other: Any stated language other than English or Spanish. Declined: A person who is unwilling to state a language preference. Unavailable: Patient is physically unable to respond.

11. Questions?

12. Let’s walk through the data template…

13. When Entering Data • Double check that your hospital name appears on the spreadsheets before submitting. • Check that all data checks are highlighted GREEN; if data checks are in RED, make sure to correct your data before submitting it. • Leave zeros in the cells with no data.

14. Questions?