Hospital-Associated Infections Data NUR630
Benchmark – Hospital-Associated Infections Data
Benchmark Assessment Description
The purpose of this assignment is to examine health care data on hospital-associated infections and determine the best methods for presenting the data to stakeholders. Use the scenario below and the “Hospital Associated Infections Data” Excel spreadsheet to complete the assignment. Hospital-Associated Infections Data NUR630
Scenario
You have been tasked with displaying Centers for Medicare and Medicaid Services (CMS) hospital quality measures data for a 5-year period on four quality measures at your site. After examining the data, identify trends and determine the best way to present the actionable information to stakeholders.
Assignment
Create a 12-15-slide PowerPoint (not including title and reference slides) presenting the data to the stakeholders. Address the following in your PowerPoint:
What conclusions can be drawn for each quality measure over the 5-year period?
What trends do you see for each quality measure over the 5-year period?
When comparing each quality measure, is the quality measure better than, worse than, or no different from the national benchmark over time?
Based on your examination of the data, which of the quality measures should you prioritize and why?
Develop a quality improvement metric and related measures to improve care processes, outcomes, and the patient experience relating to the identified area of opportunity.
Explain how you would monitor the metric and use collected data for improvement.
Include a title slide, references slide, and comprehensive speaker notes.
Refer to the resource, “Creating Effective PowerPoint Presentations,” located in the Student Success Center, for additional guidance on completing this assignment in the appropriate style. Hospital-Associated Infections Data NUR630
Use a minimum of two peer-reviewed, scholarly sources as evidence.
While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
You are not required to submit this assignment to LopesWrite.
Benchmark Information
This benchmark assignment assesses the following programmatic competency:
MSN Leadership in Health Care Systems
6.6: Develop and monitor continuous quality improvement metrics and measures to improve care processes, outcomes, and the patient experience. Hospital-Associated Infections Data NUR630
Attachments
NUR-630-RS-HospitalAssociatedInfectionsDat
Hospital Name Measure Name Measure ID Measure Start Date Measure End Date National Benchmark Score Footnote
ABC Health Surgical Site Infection from colon surgery (SSI: Colon) HAI_3_SIR 1/1/2015 9/30/2015 2.548 3.555
ABC Health Central line-associated blood stream infections (CLABSI) HAI_1_SIR 1/1/2015 9/30/2015 3.422 3.422
ABC Health Catheter-Associated Urinary Tract Infections (CAUTI) HAI_2_SIR 1/1/2015 9/30/2015 1.231 0.466
ABC Health Surgical Site Infection from abdominal hysterectomy (SSI: Hysterectomy) HAI_4_SIR 1/1/2015 9/30/2015 2.703 4.608
ABC Health Surgical Site Infection from colon surgery (SSI: Colon) HAI_3_SIR 1/1/2014 12/31/2014 2.319 2.487
ABC Health Central line-associated blood stream infections (CLABSI) HAI_1_SIR 1/1/2014 12/31/2014 3.063 3.063
ABC Health Catheter-Associated Urinary Tract Infections (CAUTI) HAI_2_SIR 1/1/2014 12/31/2014 1.089 0.567
ABC Health Surgical Site Infection from abdominal hysterectomy (SSI: Hysterectomy) HAI_4_SIR 1/1/2014 12/31/2014 2.512 3.697
ABC Health Surgical Site Infection from colon surgery (SSI: Colon) HAI_3_SIR 3/1/2013 11/30/2013 2.219 2.219
ABC Health Central line-associated blood stream infections (CLABSI) HAI_1_SIR 3/1/2013 11/30/2013 3.128 3.062
ABC Health Catheter-Associated Urinary Tract Infections (CAUTI) HAI_2_SIR 3/1/2013 11/30/2013 Not available Not available 4 – Data suppressed by CMS for one or more quarters.
ABC Health Surgical Site Infection from abdominal hysterectomy (SSI: Hysterectomy) HAI_4_SIR 3/1/2013 11/30/2013 2.094 2.094
ABC Health Surgical Site Infection from colon surgery (SSI: Colon) HAI_3_SIR 1/1/2012 12/31/2012 2.136 0.174
ABC Health Central line-associated blood stream infections (CLABSI) HAI_1_SIR 1/1/2012 12/31/2012 2.089 2.203
ABC Health Catheter-Associated Urinary Tract Infections (CAUTI) HAI_2_SIR 1/1/2012 12/31/2012 0.827 0.827
ABC Health Surgical Site Infection from abdominal hysterectomy (SSI: Hysterectomy) HAI_4_SIR 1/1/2012 12/31/2012 2.132 2.132
ABC Health Surgical Site Infection from colon surgery (SSI: Colon) HAI_3_SIR 1/1/2011 12/31/2011 2.234 0.273
ABC Health Central line-associated blood stream infections (CLABSI) HAI_1_SIR 1/1/2011 12/31/2011 2.234 2.845
ABC Health Catheter-Associated Urinary Tract Infections (CAUTI) HAI_2_SIR 1/1/2011 12/31/2011 1.879 2.814
ABC Health Surgical Site Infection from abdominal hysterectomy (SSI: Hysterectomy) HAI_4_SIR 1/1/2011 12/31/2011 2.133 1.148
Hospital-Associated Infections Data NUR630 Topic 7 DQ 1
Identify at least two stakeholder agency reporting sources. How do these external reporting groups contribute to or hinder CQI?
Topic 7 DQ 2
You are going to present data that have been collected to your administrative group. The focus is on outcome measures and the data collected are unplanned readmission rates at two different hospitals. What format would you choose to display your data and why? What information would you include with the data?
Hospital-Associated Infections Data NUR630 Resources
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Continuous Quality Improvement in Health Care
Review Chapter 4 in Continuous Quality Improvement in Health Care.
View Resource
Hospital-Associated Infections Data NUR630
Washington Manual of Patient Safety and Quality Improvement
Read Chapter 6 in Washington Manual of Patient Safety and Quality Improvement.
View Resource
Performance Improvement: Stages, Steps and Tools
Explore the Performance Improvement: Stages, Steps and Tools page of the IntraHealth International website. Hospital-Associated Infections Data NUR630
https://www.intrahealth.org/sst/index.html
Serious Reportable Events
Explore the Serious Reportable Events page located on the National Quality Forum website.
http://www.qualityforum.org/Topics/SREs/Serious_Reportable_Events.aspx
Talking Quality: Reporting to Consumers on Health Care Quality
Explore the Talking Quality: Reporting to Consumers on Health Care Quality page of the Agency for Healthcare Research and Quality (AHRQ)
… Read More
https://www.ahrq.gov/talkingquality/index.html
Medicare Initiatives Improve Hospital Care, Patient Safety
Read “Medicare Initiatives Improve Hospital Care, Patient Safety,” by Conway, from The Hospitalist (2015).
https://www.the-hospitalist.org/hospitalist/article/122300/health-policy/medicare-initiatives-improve-hospital-care-patient-safety
Optimize Data Visualization to Improve Communication About Quality Improvement
Read “Optimize Data Visualization to Improve Communication About Quality Improvement,” by AHC Media, from Case Management
… Read More
https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=139844155&site=ehost-live&scope=site&custid=s8333196&groupid=main&profile=ehost
The Effectiveness of Continuous Quality Improvement for Developing Professional Practice and Improving Health Care Outcomes: A Systematic Review
Read “The Effectiveness of Continuous Quality Improvement for Developing Professional Practice and Improving Health Care Outcomes: A
… Read More
https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=142792426&site=ehost-live&scope=site&custid=s8333196&groupid=main&profile=ehost
Measuring Patient Safety: The Medicare Patient Safety Monitoring System (Past, Present, and Future)
Read “Measuring Patient Safety: The Medicare Patient Safety Monitoring System (Past, Present, and Future)” by Classen, Munie
… Read More
https://oce-ovid-com.lopes.idm.oclc.org/article/01209203-202104000-00030/HTML
A Primer on Data Visualization in Infection Prevention and Antimicrobial Stewardship
Read “A Primer on Data Visualization in Infection Prevention and Antimicrobial Stewardship,” by Salinas, Kritzman, Kobayashi, Edm
… Read More
https://oce-ovid-com.lope
Benchmark – Hospital-Associated Infections Data – Rubric
Introduction:
The Centers for Medicare and Medicaid Services (CMS) hospital quality measures data for a 5-year period on four quality measures at ABC Health has been examined. The four quality measures were Surgical Site Infection from colon surgery (SSI: Colon), Central line-associated bloodstream infections (CLABSI), Catheter-Associated Urinary Tract Infections (CAUTI), and Surgical Site Infection from abdominal hysterectomy (SSI: Hysterectomy). In this PowerPoint presentation, the conclusions that can be drawn from the data, trends observed, and comparisons with national benchmarks will be discussed. Also, the priority quality measure to improve will be determined, and a quality improvement metric and related measures will be developed. Lastly, the monitoring and use of collected data for improvement will be explained.
Conclusion for Each Quality Measure over the 5-Year Period:
Surgical Site Infection from Colon Surgery (SSI: Colon):
The SSI: Colon measure score for ABC Health decreased from 3.555 in 2015 to 0.174 in 2012. The scores were above the national benchmark in all the years except for 2012, where the score was lower. A consistent downward trend was observed in the scores from 2015 to 2012, indicating an improvement in the quality measure.
Central Line-Associated Bloodstream Infections (CLABSI):
The CLABSI measure score for ABC Health remained the same (3.422) in 2015 and 2014. The score was above the national benchmark in both years. A comparison of the scores for 2015 and 2014 showed that there was no significant change in the quality measure.
Catheter-Associated Urinary Tract Infections (CAUTI):
The CAUTI measure score for ABC Health increased from 0.466 in 2015 to 0.567 in 2014. The score was below the national benchmark in both years. A comparison of the scores for 2015 and 2014 showed that there was an increase in the quality measure.
Surgical Site Infection from Abdominal Hysterectomy (SSI: Hysterectomy):
The SSI: Hysterectomy measure score for ABC Health increased from 4.608 in 2015 to 3.697 in 2014. The score was above the national benchmark in both years. A comparison of the scores for 2015 and 2014 showed that there was a decrease in the quality measure.
Trends for Each Quality Measure over the 5-Year Period:
Surgical Site Infection from Colon Surgery (SSI: Colon):
A consistent downward trend was observed in the SSI: Colon scores from 2015 to 2012. The score decreased from 3.555 in 2015 to 0.174 in 2012, indicating an improvement in the quality measure.
Central Line-Associated Bloodstream Infections (CLABSI):
No significant change was observed in the CLABSI scores from 2015 to 2014. The score remained the same (3.422) in both years.
Catheter-Associated Urinary Tract Infections (CAUTI):
An increase in the CAUTI score was observed from 0.466 in 2015 to 0.567 in 2014, indicating a worsening of the quality measure.
Surgical Site Infection from Abdominal Hysterectomy (SSI: Hysterectomy):
A decrease in the SSI: Hysterectomy score was observed from 4.608 in 2015 to 3.697 in 2014, indicating an improvement in the quality measure.
Comparison of Each Quality Measure with National Benchmark over Time:
Surgical Site Infection from
