© The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011

CUSP for VAPRevisiting Your Action Plan: Using Reports to Drive ChangeSara Cosgrove, MD, MS

Donna Fellerman, RN, CIC

Chelsea Lynch, RN, MSN, MPH, CIC

Elizabeth Zink, MS, RN, CCNS, CNRN

Polly Trexler, MS, CIC

July 10, 2014

***Please note some slides have been removed since the webinar at the presenter’s request.

Data Drives Outcomes

• How to Present Your Data

Effectively

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Define the Audience

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• Front-line clinicians

• Clinical committees (e.g., critical care committee)

• Hospital administration

• Patients/families

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Define the Purpose of Sharing the Data

• Assessment of individual cases to determine areas for improvement

• Trending of data over time to compare units to themselves or other units

• Dashboards or other quality improvement documents– Usually red, yellow, green– Decide in advance how these will be defined

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Define the Message

• What do you want them to take away?

• This is often in flux and needs to re-evaluated frequently

Rate trending upwards in a clinically significant wayNeeds to be addressed now

Rate is very lowNothing to worry aboutKeep up the good work

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Address Concerns about Data Validity Upfront

• Share the surveillance definitions and how you perform surveillance– Describe data sources– Repeat often

• Point out limitations and definitional cases without negating the validity of the data

• Distinguish between the surveillance definition and the clinical definition

• Allow time for venting, but rally the team back– Complaining is not going to make the CDC change the

definition!– Everyone follows the same rules

CDC VAE Surveillance

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Determine How to Display the Data

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• Numbers (numerators) vs. rates

• Time frames

– Weekly, monthly, quarterly, etc.

– Depends on how common the event is

• Benchmarks

– CDC or other

• Process and outcome measures on the same graph?

• Indicators of when interventions started

• Annual goals/targets

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Suggestions Based on Audience

• Front-line clinicians– Numbers of cases– Weeks since last

case– Process

measures– Graphs with rates– Goals &

benchmarks– Action plan

• Administrators– Graphs with rates– High level process

measure information– Goals & benchmarks– Action plan

• Patients/families– Tailor message to

request

Head of Bed > 30⁰

Oral Care with CHGSubglottic Suctioning

Sedation Vacation

Daily Assessment for Readiness to Wean

How are we doing?Post the unit’s VAP graph or other information here

Be a VAP Preventio

nSTAR!

Bundle Up!

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Change the Data Display When Necessary

• Data display should be an iterative process– Base changes on questions from and

interpretations of audience

• Particularly difficult with VAC, IVAC, possible and probable VAP

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Process Measures

• Process measure data is only as good as the data collection

• Need to have and apply a standard definition, which is challenging when numerous people are collecting

• More appropriate for unit level trending and initiation of discussions regarding improvement than for reporting at high-level meetings

Keep it Visible

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• Give internal access (such as an intranet source)• Post it where staff can see it

• Personally take it to where

staff are working (on units)

A unit “huddle” – taking information to staff and gaining feedback/ideas rather than waiting for a formal group meeting

Keep it Timely

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• Stay on schedule with data reports to committees

• Distribute as soon as possible to stakeholders– Use multiple opportunities – staff meetings,

provider meetings, QI meetings, rounds, “huddles”

Make it Meaningful

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• WHO does this dot on a graph represent?

• Tell the patient’s story. Use patients’ names for unit personnel. They will remember the patient and may have ideas for improvements in practice or products

• Have an expectation that front line staff can answer how the unit is doing with VAP, CLABSI, CAUTI when asked

Conclusions

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• Manage the message

• Make the data visible, interpretable, and timely– Solicit input from stakeholders about effective

ways to do this

• Make it meaningful—we are talking about patients

© The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011

Project Updates and Next Steps

Next Steps

• Collect Process Measure data (7 days of data per month

collected during the 1st week of the month)

• Collect Early Mobility data (7 days of data per month

collected during the 2nd week of the month)

• Complete Structural Assessment 3 (begins next week)

• Data collection for Low Tidal Volume Ventilation measure

(August)

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Additional Resources

• For questions regarding data collection, email us at cuspevap@jhmi.edu

• Society for Critical Care Medicine ICU Liberation Group– http://www.iculiberation.org/Pages/default.aspx

• AHRQ CUSP Toolkit– http://www.ahrq.gov/professionals/education/curriculum-tools/cusptool

kit/

• Armstrong Institute CUSP Tools– http://

www.hopkinsmedicine.org/armstrong_institute/training_services/cusp_offerings/cusp_guidance.html

• Armstrong Institute Training Opportunities– http://www.hopkinsmedicine.org/armstrong_institute/training_services/

cusp_offerings/

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Thank You

A sincere

THANK YOU

for all of your effort

and hard work to

reduce the incidence of VAP

in your units

and prevent HAIs!