Decreasing BSI QIA January Monthly Feedback Report

Form due by February 10, 2020

Please only send one report per facility

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* 1. Facility CCN and Facility Name

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* 2. Project Lead Submitting Form:

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* 3. Project Lead Email

Infection Data Tracking

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* 4. How many bloodstream infections did your facility have in January?

(Enter 0 if 0)

100

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 5. Please briefly describe the source(s) of each infection; If there were no infections, type N/A: (Please do not include any direct patient health information)

Prevention Tracking: Infection Control Audits Completed in January

Please indicate the number of audits completed for each category.

Note: Based on the requirements of this project we ask that each clinic complete at least 20 audit types among any of the given categories and 5 additional infection prevention audits that are completed by patients. Clinics may choose which types of audits to complete based on individual needs. Reporting example: if a completed audit includes assessment of Hand Hygiene, Dialysis Station Disinfection, and Cannulation Prep, that is reported as 3 infection prevention audits. A “perfect” outcome is a deficiency-free audit.

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* 6. Total Number of audit categories completed:

100

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 7. Number of patient-performed Audits:

100

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 8. Number of Hand Hygiene Audits:

100

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 9. Number of Perfect Hand Hygiene Outcomes:

100

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 10. Number of AV Fistula/Graft Cannulation prep Audits:

100

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 11. Number of Perfect cannulation prep Outcomes:

100

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 12. Number of Catheter Care Audits:

100

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 13. Number of Perfect Catheter Care Outcomes:

100

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 14. Number of Dialysis Station Disinfection Audits:

100

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 15. Number of Perfect Dialysis Station Disinfection Outcomes:

100

Clear

i We adjusted the number you entered based on the slider’s scale.

January Highlighted Resource/Activity

In January, you received a Kickoff Package, including QIA calendar, Kickoff webinar, Huddle Helper Checklist, Network Patient Representative application, and My ESRD Network flyer.

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* 16. Regarding the QIA Project Calendar, please rate the usefulness of this resource to assist with tracking of QIA items:

1—Very Beneficial

2—Somewhat Beneficial

3—Undecided

4—Not very beneficial

5—Not beneficial at all

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* 17. Regarding the QIA Kickoff Webinar/PDF Slides, please rate the usefulness of this resource to assist with understanding the QIA requirements:

1—Very Beneficial

2—Somewhat Beneficial

3—Undecided

4—Not very beneficial

5—Not beneficial at all

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* 18. When thinking about the QI processes that were discussed in the Kickoff Webinar (Rapid Cycle Improvement, Root Cause Analysis, SMART Goals, PDSA, Sustainability) please select all that apply:

I learned something new from this webinar

I found the webinar to be useful to better explain quality improvement processes

As a result of this webinar, I will be changing something in my current process regarding how I complete QI projects in my clinic (not just this QIA)

As a result of this webinar, I feel better equipped to complete the QIA

I knew most of what was presented but it was a helpful reminder for me to hear again

I didn’t think the kickoff webinar was worthwhile

I have not yet listened to the webinar

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* 19. With regard to the Huddle Helper Checklist, how did you use the resource? Please check all that apply:

Began using the checklist during staff huddles

Discussed the resource in a staff meeting to begin working on implementation

Asked applicable team members to review the resource but did not share with everyone

Shared the resource in a QAPI meeting or with the Medical Director (or plan to)

Shared the resource with another clinic or with regional leadership

I have not yet implemented the resource but plan to

I did not find the resource to be beneficial and I do not plan to use it

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* 20. CMS expects that dialysis providers share ESRD Network information with patients. You were asked to print and share the My ESRD Network flyer with your patients. Did you share this with your patients?

Yes, we shared in January

We plan to share in February

We do not plan to share

QIA LAN Attendance

The Bloodstream Infections QIA LAN presentation held on January 7th featured Associate Directors of Patient and Family Engagement for the ESRD NCC Jerome A. Bailey, BA and Kim Buettner, BA sharing their respective roles to support the National Patient and Family Engagement (NPFE) LAN; the call also featured a patient Subject Matter Expert (SME) from the NCC’s BSI Affinity Group. The presentation highlighted resources created by the NPFE-LAN BSI Affinity Group and share methods for spreading the resources with patients.

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* 21. Regarding the ESRD NCC Decreasing BSI QIA LAN Call mentioned above please choose the best answer:

Someone from my clinic attended the live QIA LAN presentation and learned at least one promising practice that we plan to implement in our clinic

Someone from my clinic attended the LAN but we are unsure about how to apply the information to our clinic

Someone from my clinic attended the LAN but did not find it relevant to our clinic

We did not participate in the live event but plan to listen to the recording when it is released

Patient Engagement

In January, the Network offered a Patient Engagement Resource to help recruit patients to incorporate into the activities of this QIA.

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* 22. With regard to the above-mentioned resource/activity, how did you use it? Please check all that apply:

Posted an announcement in a common area for reviewing at patient convenience

Discussed the resource in a staff huddle prompting staff to share it with patients

Discussed the resource with staff so they could answer patient questions if needed

Shared the resource in a QAPI meeting or with the Medical Director

Shared the resource with another clinic or with regional leadership

I have not yet shared the resource but plan to

I did not find the resource to be beneficial and I do not plan to use it

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* 23. Have you been able to recruit a patient (or patients) to incorporate into the activities of this QIA?

Yes, we have at least one patient who is able to work with us

We are still working on getting someone

We would like more explanation of the role

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* 24. How many care plan meetings did you complete this month?

100

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 25. How many care plan meetings did you complete this month?

Note: Attended the care plan meeting may be defined as: meeting with the patient chairside in the development and assessment for the plan of care, meeting in a conference room or other area to discuss and review the plan of care, meeting virtually using a phone or webcam to discuss the plan of care with the patient/family member(s).

100

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 26. Does your facility coordinate (or provide information on) established patient support groups OR new patient adjustment groups OR patient councils?

Yes

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* 27. Does your facility include patients and/or family/caregivers in the Quality Assurance Performance Improvement (QAPI) Program and/or governing body of the facility?

Yes

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* 28. Goal 1: Network Patient Representative in each dialysis facility in the Network region.

This month, my facility: (Mark all that apply)

Had a team discussion to identify a NPR for our facility.

Assisted a patient/caregiver/family member to complete a NPR application

Worked with our active NPR

Encouraged NPR to attend the NPR Connection Call

Reviewed the monthly NPR Connection e-newsletter with the NPR to identify opportunities

Planned a patient engagement activity

Conducted a patient engagement activity (please elaborate on other)

None of the above

Other (please specify)

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* 29. Goal 2: Increased patient/family involvement in the development of their plan of care and/or plan of care meeting.

What actions did your facility take to impact this goal this month?

Reviewed Network resources

Met with NPR to discuss patient perspective on meeting the goal

Discussed during QAPI strategies to improve patient attendance

Implemented a strategy to increase participation

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* 30. How many care plan meetings did you complete this month?

100

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 31. How many patients/family members attended these care plan meetings?

100

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 32. How many attended their meeting (with all team members) with the patient chairside in the development and assessment for the plan of care?

100

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 33. How many patients/family members attended a meeting in a conference room or other area to discuss and review the plan of care?

100

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 34. How many patient/family member(s) attended a meeting virtually using a phone or webcam to discuss the plan of care?

100

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 35. How many patients had their POC reviewed with them following the POC meeting?

100

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 36. Goal 3: Facilities will establish patient support groups; new patient adjustment groups and/or patient councils.

What actions did your facility take to impact this goal this month?

Reviewed Network resources

Met with the NPR to discuss opportunities for engaging patients in groups

Assessed patient interest in groups

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* 37. Does your facility coordinate (or provide information on) established patient support groups OR new patient adjustment groups OR patient councils?

Yes

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* 38. This month our facility…

Hosted a patient support group

Hosted a new patient adjustment group

Hosted a patient council meeting

Hosted an activity to encourage peer to peer support

Provided information on groups available

None of the above

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* 39. Goal 4: Facilities will include patients and/or family/caregivers in the Quality Assurance Performance Improvement (QAPI) Program and/or governing body.

Does your facility include patients and/or family/caregivers in the Quality Assurance Performance Improvement (QAPI) Program and/or governing body of the facility?

Yes

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* 40. What actions did your facility take to impact this goal this month?

Reviewed Network resources

Identified patient/family member to participate in QAPI

Discussed patient involvement during QAPI team meeting to plan for patient/family member attendance

Provided patient with invitation to participate

Patient/family member attended the QAPI team meeting

None of the above

Decreasing BSI QIA January Monthly Feedback Report

Question Title

* 1. Facility CCN and Facility Name

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* 2. Project Lead Submitting Form:

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* 3. Project Lead Email

Question Title

* 4. How many bloodstream infections did your facility have in January?(Enter 0 if 0)

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* 5. Please briefly describe the source(s) of each infection; If there were no infections, type N/A: (Please do not include any direct patient health information)

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* 6. Total Number of audit categories completed:

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* 7. Number of patient-performed Audits:

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* 8. Number of Hand Hygiene Audits:

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* 9. Number of Perfect Hand Hygiene Outcomes:

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* 10. Number of AV Fistula/Graft Cannulation prep Audits:

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* 11. Number of Perfect cannulation prep Outcomes:

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* 12. Number of Catheter Care Audits:

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* 13. Number of Perfect Catheter Care Outcomes:

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* 14. Number of Dialysis Station Disinfection Audits:

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* 15. Number of Perfect Dialysis Station Disinfection Outcomes:

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* 16. Regarding the QIA Project Calendar, please rate the usefulness of this resource to assist with tracking of QIA items:

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* 17. Regarding the QIA Kickoff Webinar/PDF Slides, please rate the usefulness of this resource to assist with understanding the QIA requirements:

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* 18. When thinking about the QI processes that were discussed in the Kickoff Webinar (Rapid Cycle Improvement, Root Cause Analysis, SMART Goals, PDSA, Sustainability) please select all that apply:

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* 19. With regard to the Huddle Helper Checklist, how did you use the resource? Please check all that apply:

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* 20. CMS expects that dialysis providers share ESRD Network information with patients. You were asked to print and share the My ESRD Network flyer with your patients. Did you share this with your patients?

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* 21. Regarding the ESRD NCC Decreasing BSI QIA LAN Call mentioned above please choose the best answer:

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* 22. With regard to the above-mentioned resource/activity, how did you use it? Please check all that apply:

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* 23. Have you been able to recruit a patient (or patients) to incorporate into the activities of this QIA?

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* 24. How many care plan meetings did you complete this month?

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* 26. Does your facility coordinate (or provide information on) established patient support groups OR new patient adjustment groups OR patient councils?

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* 27. Does your facility include patients and/or family/caregivers in the Quality Assurance Performance Improvement (QAPI) Program and/or governing body of the facility?

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* 28. Goal 1: Network Patient Representative in each dialysis facility in the Network region.This month, my facility: (Mark all that apply)

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* 29. Goal 2: Increased patient/family involvement in the development of their plan of care and/or plan of care meeting.What actions did your facility take to impact this goal this month?

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* 30. How many care plan meetings did you complete this month?

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* 31. How many patients/family members attended these care plan meetings?

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* 32. How many attended their meeting (with all team members) with the patient chairside in the development and assessment for the plan of care?

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* 33. How many patients/family members attended a meeting in a conference room or other area to discuss and review the plan of care?

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* 34. How many patient/family member(s) attended a meeting virtually using a phone or webcam to discuss the plan of care?

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* 35. How many patients had their POC reviewed with them following the POC meeting?

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* 36. Goal 3: Facilities will establish patient support groups; new patient adjustment groups and/or patient councils.What actions did your facility take to impact this goal this month?

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* 37. Does your facility coordinate (or provide information on) established patient support groups OR new patient adjustment groups OR patient councils?

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* 38. This month our facility…

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* 40. What actions did your facility take to impact this goal this month?

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* 4. How many bloodstream infections did your facility have in January?

(Enter 0 if 0)

* 28. Goal 1: Network Patient Representative in each dialysis facility in the Network region.

This month, my facility: (Mark all that apply)

* 29. Goal 2: Increased patient/family involvement in the development of their plan of care and/or plan of care meeting.

What actions did your facility take to impact this goal this month?

* 36. Goal 3: Facilities will establish patient support groups; new patient adjustment groups and/or patient councils.

What actions did your facility take to impact this goal this month?