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National Health Safety Network QIA

Deb DeWalt, MSN, RN Sue Swan-Blohm, BS, OCDT March 3, 2017

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Agenda

Project Overview:

Inclusion Criteria

Project Goals

Project Paperwork

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Why am I in this project?

There will be three co-horts for this project

This is co-hort one

Twenty dialysis clinics

Five hospitals

Identify clusters of facilities reporting to same hospital

No EMR access

Inconsistent reporting of BSI results

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Project Goals

To close identified gap of inconsistent reporting of BSI by dialysis facilities, and improve NHSN reporting of dialysis patient Positive Blood Cultures (PBC) collected in hospitals within two calendar day after hospitalization

Improve communication for both the purposes of surveillance of BSI and quality of care for patients

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View of reporting screen in NHSN

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Identified Barriers to Accurate BSI Reporting

Unsuccessful strategies for collecting PBC data from hospitals

Hospital staff not aware of the requirement to report PBC data to dialysis facility

Inconsistent provision of records related to PBC

No point person at the dialysis facility to follow up on hospitalizations

Large dialysis organizations (LDO) have centralized reporting systems and data is imported from LDO data systems to NHSN. Several facilities that are affiliated with LDO’s do not have access to NHSN on local level.

Hospitals may not release information under HIPAA

Access to hospital EMR is not easy to obtain

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Sharing of information? What about HIPPA?

The HIPAA Privacy Rule permits a covered entity to use or disclose PHI for certain “health care operations” purposes without the authorization of the patient. 45 CRF 164.506 (c)…this includes a covered entity disclosing PHI to another covered entity for certain purposes if each entity either has or had a relationship with the individual who is the subject of the of the information. 45 CFR 164.506 (c)…

www.cste.org/resource/resmgr/2016/16.ID.09.pdf

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Communication Tools

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Hospitals Involved in Project

MetroHealth

SouthPointe

Hillcrest

Marymount

Euclid

Cleveland Clinic Main Campus

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Any Questions?

Victoria Cash, MBA, BSN, RN Executive Director vcash@nw9.esrd.net James Hrubik, BS Assistant Director, Information Management rhrubik@nw9.esrd.net Debbie DeWalt, MSN, RN Assistant Director, Quality Improvement ddewalt@nw9.esrd.net Andrea Bates, MSW Patient Services Coordinator abates@nw9.esrd.net

Nina Pollard, MPH Contract Manager npollard@nw9.esrd.net Jerome Jemison, BS Data Coordinator jjemison@nw9.esrd.net Susan Swan-Blohm, BS, OCDT Quality Improvement Coordinator sswan-blohm@nw9.esrd.net

3201 Enterprise Parkway, Suite 201, Beachwood, OH 44122 Phone: (216) 593-0001 Fax: (216) 593-0101

IPRO ESRD Network of the Ohio River Valley (Network 9)