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QSource Update:
Reducing Hospital Infections
Manoj Jain, MD, MPH
Medical Director, QSource
11 March, 2009 - Memphis
17 March, 2009 - Knoxville
26 March, 2009 - Nashville
Objectives for Today:
• Vision/Mission
• Major Initiatives in TN by QIO and TN Center for
Patient Safety (TCPS) on MRSA/SCIP
• QSource/TCPS MRSA/SCIP Crosswalk
• Model for Change Within the MDRO Module
• Other Present and Future Initiatives
• Preparing for the Future
“The right care
for every person,
every time.”
CMS Vision Statement
for the National
Healthcare Quality
Improvement Program
The “Right Care”
• Safe
• Timely
• Effective
• Efficient
• Equitable
• Patient-centered
The Institute of Medicine
MRSA and SCIP – QSource and TCPS
Two Parallel, Overlapping, and
Synergistic Initiatives
• History
• Recruitment
• Measures
• Intervention
• Evaluation
Historical Perspectives:
• Aug 2008 thru July 2011 –
3 year timeframe
• Funding from CMS through
QIOs
• Clinical Advisors - Manoj
Jain, MD, MPH; Marion
Kainer, MD
• Team Leaders – QSource
Patient Safety Team
• Jan 2008 thru Jan 2010 –
2 year timeframe
• Funding from TN BC-BS
Health Foundation
thru THA TCPS
• Clinical Advisors – Peter
Pronovost, MD & Chris
Goeschel; Marion Kainer, MD
• Team Leader - V/P and
Director TCPS
Recruitment Outcomes:
• MRSA
30 Hospitals
• MRSA
63 Hospitals
• SCIP
22 Hospitals
• SCIP
69 Hospitals
SCIP Measure Comparisons:
• SCIP Inf-1 Antibiotic Administration within
One Hour Before Incision
• SCIP Inf-2 Use of Antimicrobial
Recommended in Guideline
• SCIP Inf-3 Antibiotic Discontinuation
within 24 Hours of Surgery End
• SCIP Inf-4 Glucose Control in Cardiac
Surgery Patients
• SCIP Inf-6 Appropriate Hair Removal
• SCIP-VTE-1 Recommended VTE
Prophylaxis Ordered
• SCIP-VTE-2 Received Appropriate VTE
Prophylaxis within 24 Hours After Surgery
• SCIP Inf-1 Antibiotic Administration within
One Hour Before Incision
• SCIP Inf-2 Use of Antimicrobial
Recommended in Guideline
• SCIP Inf-3 Antibiotic Discontinuation
within 24 Hours of Surgery End
• SCIP Inf-4 Glucose Control in Cardiac
Surgery Patients
• SCIP Inf-6 Appropriate Hair Removal
• SCIP Inf-7 Normothermia
• SCIP-VTE-1 Recommended VTE
Prophylaxis Ordered
• SCIP-VTE-2 Received Appropriate VTE
Prophylaxis within 24 Hours After Surgery
MRSA Measure Comparisons:
• MRSA-1 MRSA Infection Rate – MRSA
healthcare-associated infections that
are not present or incubating on
admission to the identified unit
• MRSA-2 Hospital Onset MRSA
Incidence Rate Based on Clinical
Cultures – a proxy measure of MRSA
infections based on clinical cultures that
have a hospital-onset
Required:
• # of Admissions to Specific Unit During
Reporting Period or Facility Wide
• # of Patient Days in Specific Unit
During Reporting Period or Facility
Wide
• Hospital Onset MRSA (all cultures)
Optional Measures Also Reportable
(See Crosswalk)
MRSA/SCIP Intervention Similarities:
• Intensive Approach
• Onsite visits
• Assistance with AHRQ
Survey
• Teach TeamSTEPPS
Methodology
• Conference Calls
• Webinars
•
•
•
•
•
Broader Approach
Regional Workshops
Statewide Meetings
Monthly Conference Calls
Assistance with AHRQ
Survey
• Webinars
MRSA/SCIP Parallel Reporting
Techniques:
• SCIP – monthly through
TCPS Website
• SCIP – monthly through
TCPS Website
• MRSA – monthly through
MDRO Module
• MRSA – monthly through
TCPS Website
MRSA/SCIP Evaluation and Feedback
Comparisons:
• Monthly data feedback
with comparisons/
benchmarks
• Monitor closely and
intervene as needed
• Monthly data feedback
with comparisons/
benchmarks
• Provide assistance
as requested
Summary of Parallel Initiatives:
• Collecting Many of the Same Measures
• AHRQ Survey
• Monthly Reporting of Measures
• Conference Calls with Clinical Advisors
• Monthly Feedback of Data with Benchmarking
Data/Comparison to Other Collaborators
Health Research and Educational Trust
(HRET)
• Effort to Replicate Successes of Michigan
Keystone Project Nationally
• Conducting in Conjunction with American
Hospital Association (AHA)
• Comprehensive Unit-Based Safety Program
(CUSP) – Can Be Focused on Any Topic
• To Pilot Soon in 10 States Through QIOs and
State Hospital Associations
• TN is Ahead of the Game Thanks to THA/TCPS!
MDRO Module – Present CDC/CMS
Model for Change
Key Elements of MDRO Module
• Use of Module to Monitor at Least One
Inpatient Unit with High MRSA Rates
• Enables Hospitals to Conduct MRSA
“Infection Surveillance” and Lab-ID Event
Reporting”
• Enables Hospitals to Collect Data on
Process Measures (Hand Washing, Barrier
Precautions, etc.)
• Hospitals Can Also Choose to Collect
Data on CDAD
When MDRO Module goes “Live”:
• Statewide QSource Trainings in
Collaboration with Dr. Marion Kainer on the
Electronic Tool/Module
• Tentatively Scheduled for April 2009
• To be Held in 3 Cities Across the State
• CMS Baseline Timeframe Began 2/1/09
• Monthly Data Entry Expectation
Other QSource and TCPS Initiatives:
QSource:
• Crossing the Continuum – NH and
Hospital Pressure Ulcer Project
• Drug Safety – Looking at Potentially
Inappropriate Medications and Drug-toDrug Interactions in Part D Data
TCPS:
• Central Line Blood Stream Infections
(CLBSI)
Reporting Hospital Quality Data for
Annual Payment Update (RHQDAPU):
• March 12th THA/QSource Webinar on the
Release of the Dry Run Version of Hospital
Specific Reports on AHRQ Measures
• Latest HQA Preview Report for Discharge
Quarters Q3 07 through Q2 08 – Withholding
Period Ended 2/17/09; to go Live on Hospital
Compare March 2009
Next QSource Statewide Abstraction
Clinic:
• March 19, 2009 from 9:00-10:30 CST
• To Highlight Changes to Q2/Q3 2009
Specifications Manual and Abstraction
Guidelines
Why Do Some Hospitals Succeed?
JAMA May 23/30, 2001 vol285, No 20
• Shared Goals for Improvement
• Substantial Administrative Support
• Strong Physician Leadership
• Credible Data Feedback
5 Strategies to Stay Off “The List”!
• Prepare – Know Your Numbers
• Have a Team to Deploy/Assist with Efforts
• Learn and Teach QI to All – IP/Nurse Manager/
Front Line Staff
• Make a Business Case for Infection Prevention
• Get Leadership Engaged and Boards on Board
What QI/IP Staff Need to Be Doing NOW
• You are the Change Agent and Knowledge Base
for Quality Improvement and Infection Prevention
in Your Institution.
– Culture Change/Work Together
– Institute Concurrent Care Management
– Standardize Infection Processes (Use “Opt Out”
Approach for Order Sets)
– Conduct Informal “RCA” of Cases that Fall Out
– Engage Physicians
– ASK Frontline Staff and Feedback Data Regularly
“The right care
for every person,
every time.”
CMS Vision Statement
for the National
Healthcare Quality
Improvement Program
Thank You!
QSource Update:
Reducing Hospital Infections
Manoj Jain, MD, MPH
Medical Director, QSource
This presentation and related materials were developed by QSource, the Medicare Quality Improvement Organization for
Tennessee, under contract with the Centers for Medicare & Medicaid Services (CMS), a division of the Department of Health
and Human Services. Contents do not necessarily reflect CMS policy. QSOURCE-TN-109.62-2008-15