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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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Victoria Cash, MBA, BSN, RN Executive Director [email protected] James Hrubik, BS Assistant Director, Information Management [email protected] Debbie DeWalt, MSN, RN Assistant Director, Quality Improvement [email protected] Andrea Bates, MSW Patient Services Coordinator [email protected]
Nina Pollard, MPH Contract Manager [email protected] Jerome Jemison, BS Data Coordinator [email protected] Susan Swan-Blohm, BS, OCDT Quality Improvement Coordinator [email protected]
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)
