NHSN Analytics For real (and busy!) people

Transcription

1 NHSN Analytics For real (and busy!) people Part 2 Accessing and Displaying Data Jamie Moran, MSN, RN, CMSRN, CIC Martha Jaworski, MS,RN, CIC June 12, 2015

2 Qualis Health A leading national population health management organization The Medicare Quality Innovation Network - Quality Improvement Organization (QIN-QIO) for Idaho and Washington The QIO Program One of the largest federal programs dedicated to improving health quality at the local level 2

3 Objectives Review content and applications of line lists, rate tables, SIR reports and TAP reports Review output variables and usefulness of reports and exported data files Modify and generate report outputs by time and other parameters Use output data to target, measure, and communicate infection prevention goals 3

4 Last Session: Building Blocks Recording now available at 4

5 Value of using NHSN Analytic Output Benchmark internal and national Facility wide risk adjusted measures Unit or procedure specific risk adjusted measures Prioritize resources with Target Assess - Prevent reports Validate data input Check accuracy of all input Check CMS data for accuracy Use data to motivate others 5

6 Running Reports 1. Analysis: Generate Data Set 2. Analysis: Output a. Run (default settings) b. Modify a. Time b. Location c. Display parameters d. Filter criteria 3. Export data 6

7 Generate Data Set A generated data set is defined by the time that the data set was run If you add or delete data after that time, a new data set must be generated for you to see these changes. Consider whether other users may have input data since the data set was generated 7

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11 Running Reports 11

12 Types of Output Line lists Rate tables (run charts) SIR reports TAP reports 12

13 Report Options 13

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15 Line Lists 15

16 Line Lists Where? Included in: Device Associated Procedure Associated CMS reports LabID reports Why? Feedback on your data input Patient level, event level information HO/CO/COHCA designation for CDI Can be exported to an excel file 16

17 Line List Default display Default Time 17

18 Time options 18

19 Modify Line List: Display Variables 19

20 Modify Line List: Display Variables 10 Default variables Custom variables 20

21 Modified Line List 2014 events only Location & Days to event 21

22 26 pages! 22

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25 Rate Tables 25

26 Rate Tables Where? Included in: Device Associated LabID reports Why? Basis for run charts Can calculate device utilization ratios Can be viewed by location groups Can be benchmarked with location groups 26

27 By CDC location By facility location 27

28 To calculate a rate (or SIR) by Fiscal year: 1) Set Date Variable to YM; enter your fiscal year 2) Set Group by to blank Options blank groups by entire date range YH: Jan-Jun, July-Dec YM: by month YQ: by calendar quarter Yr: Jan-Dec 28

29 Pooled Mean Reference: 29

30 Run Charts Where Device Associated (CAUTI, CLABSI, VAP, VAE) Why Common format for data presentation View over time Can be viewed relative to pooled mean of like units Can be annotated with interventions 30

31 Modifiable settings: Time Group by Control Chart Options: Pooled mean Reference line 31

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33 Procedure-Associated Module 33

34 State report SIR Most inclusive SIR State report: 34

35 Line List 35

36 Standardized Infection Ratio (SIR) Reports 36

37 SIR Reports Where: For All in-plan data: Device Associated Reports (CAUTI, CLABSI) Procedure Associated Reports (SSI) LabID reports (MRSA and CDI) For data that is submitted to CMS CMS reports: CAUTI (all ICU (except NICU) and Med-surg non-icu) CLABSI (all ICU (including NICU) and Med-surg non-icu) SSI (30 day Complex colon and abd hyst) LabID (MRSA and CDI) Why: Benchmarking! Ability to add individually adjusted components 37

38 CMS Reports: SIRs CMS SIR reports are aligned with CMS IQR data requirements 38

39 Defaults: All times By quarter Grouped by: facility wide Location type CDC location type Unit Months w/ missing/0 days 39

40 Use Date Variable to set the time period of all data for report & Group by to set group time period Default CDC locations are listed in Selection Criteria. These are the locations that are included in the SIR. Current CMS SIR report for CAUTI/CLABSI includes ICU and non-icu units (from January only for non-icu) 40

41 Target Assess Prevent TAP Reports 41

42 TAP Report Content 42

43 TAP Reports Provide the facility-level CAD, by HAI type Sum of all infections (sum of all expected * HHS Target) Rank-order units (highest CAD first) within a facility Allows facilities to Target highest contributors to the overall facility CAD 43

44 HHS Goals 44

45 TAP Reports Current CAD is adjusted to the HHS goal CAD: In decreasing order of number of excess infections by unit Worse Better 45

46 TAP Reports CDC recommends using a minimum of 1 year of data for the CAD measure 46

47 TAP Reports.75 for CAUTI.50 for CLABSI.70 for CDI.75 for SSI VBP Thresholds.845 for CAUTI.457 for CLABSI.750 for CDI.751 for Colon SSI.698 for Hyst SSI 47

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49 Validating Data 49

50 General Data Validation Review Alerts Review line lists Accuracy Procedures excluded from SIR 50

51 Data Validation for CMS - IQR 51

52 CMS Reports Do infection counts and device days make sense? CMS SIR Report output: CLABSI & CAUTI SIR - Months with Missing or 0 Device Days SSI SIR - Incomplete Procedures not Included in SIR LabID SIR - Incomplete Months Excluded for SIR; Confirm that test type has been entered Consider printing summary information from CMS reports 52

53 CMS Data Check Next Deadline? 1 August 15, 2015 What time period is due to CMS? 1 Through March, 2015 Modify output to group by month and run report Is this what I thought I entered? Does this make sense historically? 1. Deadlines.pdf 53

54 Data Formats and Exporting Data 54

55 Reports 55

56 CMS Reports: SIRs 56

57 Data Formats 57

58 HTML: Default RTF(1 table per page) PDF (1 table per page) CSV 58

59 Exporting Data from NHSN 59

60 Export Data Set Export Analysis Data Set Choose format 56 data elements required to produce CLABSI SIR report 60

61 Export Output Data Set Choose format 15 data elements included in CLABSI SIR output data set 61

62 Putting it Together: Considerations for Data Presentation 62

63 Data for Motivating Staff Unit Specific (CAUTI/CLABSI) Data specific to specialty areas Over time; include interventions on runcharts Risk adjusted/benchmark for unit type CAD may be a more intuitive measure 63

64 CCU Working on nurse driven foley removal protocol Evaluate impact of intervention on rates, DUR Benchmarked by like units (rate) SIR shown Implemented Nurse Driven Foley Removal Protocol 64

65 Data Presentation for Leadership Benchmarking Risk adjustment Estimates of performance relative to reimbursement programs 65

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67 Q & A 67

68 Contacts Jamie Moran, MSN, RN, CMSRN, CIC Quality Improvement Consultant Martha Jaworski, MS,RN, CIC Quality Improvement Consultant For survey: For more information: This material was prepared by Qualis Health, the Medicare Quality Innovation Network - Quality Improvement Organization (QIN-QIO) for Idaho and Washington, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. ID/WA-C1-QH