PfP Compass HIIN Reporting Database Work Plan Template · PfP Compass HIIN Reporting Database Work...

Compass HIIN Work Plan Preparation Template page 1

PfP Compass HIIN Reporting Database Work Plan Template

Primary HIIN Contact:

Email:

Quality Lead:

Email:

Infection Preventionist:

Email:

1) Prior to scheduled admission, hospital staff provides and discusses a planning checklist that is

similar to CMS’ Discharge Planning Checklist with every patient, allowing time for questions and

comments from patient and family. ☐ YES ☐ NO

2) Hospital conducts shift change huddles and does bedside reporting with patients and family

members in all feasible cases. ☐ YES ☐ NO

3) Hospital has a dedicated person or functional area that is proactively responsible for patient and

family engagement and systematically evaluates patient and family engagement activities.

☐ YES ☐ NO

4) Hospital has an active Patient and Family Engagement Committee or at least one former patient

that serves on a patient safety or quality improvement committee or team. ☐ YES ☐ NO

5) Hospital has at least one or more patient(s) who serve on a governing or leadership board and

serves as a patient representative. ☐ YES ☐ NO

1) Hospital has regular quality review aligned with Partnership for Patients. ☐ YES ☐ NO

2) Hospital has a public commitment to safety improvement with transparency in sharing more

than CORE hospital measurement data with the public. ☐ YES ☐ NO

3) Hospital staff, all or nearly all, have a role or perceived goal in patient safety (e.g., can be explicit

in HR goals or a group bonus based on patient safety target). ☐ YES ☐ NO

4) Hospital board of trustees has a quality committee established; with regular review of patient

safety data, including review and analysis of risk events. ☐ YES ☐ NO

Hospital Information

Facility Name:

HIIN Survey Questions

Patient and Family Engagement

Leadership Criteria


Primary HIIN Contact: Name

Champion (Responsibility Party): Name

Bedside Best Practice Leader: Name

Plan to improve this focus area?

Timeline for improvement:

☐ STAAR Model

☐ Post-hospital follow-up care

☐ Real-time handover communications

☐ Implementation of community care transitions program

☐ Post discharge phone calls and follow up communication strategies

☐ Implementation of Person and family engagement (PFE) strategies

☐ Bedside huddles

☐ Implementation of discharge planning checklist

☐ Hourly rounding

☐ Enhanced assessment of discharge needs, including readmission risk assessment (LACE tool)

☐ Integration of health literacy concepts, such as Teach Back

☐ Other:

☐ PDSA (Plan, Do, Study, Act)

☐ Lean

☐ TeachBack

☐ TeamSTEPPS

☐ Other:

Readmissions

Actions/Best Practice Bundle to be Implemented: (check all that apply)

Performance Improvement Methods to be Utilized: (check all that apply)


☐ On-site technical assistance

☐ Content expert faculty

☐ Leadership

☐ Physician Engagement

☐ Data

☐ Other:

☐ QIN/QIO

☐ State Department

☐ Transforming Clinical Practice Initiative (TCPI)

☐ State Innovation Model (SIM)

☐ Community-based Care Transitions Program (CCTP)

☐ Previously worked with HIIN

☐ Other:

Does your facility have a policy for Readmissions? ☐ YES ☐ NO

Currently Working With: (check all that apply)

Opportunities for Assistance from IHC HIIN: (check all that apply)







☐ Prompt removal of unnecessary urinary catheters

☐ Nurse driven protocol

☐ Use CAUTI bundle

☐ Daily review of necessity

☐ ED implementation of CAUTI bundle

☐ Ensure aseptic insertion and maintenance techniques

☐ Conduct periodic nursing competencies

☐ Use of closed systems

☐ NHSN Surveillance and monitoring

☐ Integration of PFE in CAUTI prevention activities/education

☐ Other:


☐ Lean

☐ TeachBack

☐ TeamSTEPPS

☐ Other:

Catheter-associated Urinary Tract Infections (CAUTI)






☐ Leadership


☐ Data

☐ Other:

☐ QIN/QIO






☐ Other:

Does your facility have a policy for foley catheter insertion and maintenance? ☐ YES ☐ NO

Does your facility have a procedure for foley catheter insertion? ☐ YES ☐ NO




☐ This section does not apply to my facility.






☐ Use of insertion and maintenance bundle

☐ Use of insertion checklist

☐ NHSN surveillance and monitoring

☐ Daily review of necessity

☐ Use of chlorhexidine for dressing changes and daily skin cleaning

☐ Scrub the Hub

☐ CUSP

☐ CLIP

☐ Integration of PFE in CLABSI prevention activities/education

☐ Other:


☐ Lean

☐ TeachBack

☐ TeamSTEPPS

☐ Other:

Central Line-associated Bloodstream Infections (CLABSI)






☐ Leadership


☐ Data

☐ Other:

☐ QIN/QIO






☐ Other:

Does your facility have a policy for central line insertion and maintenance? ☐ YES ☐ NO

Does your facility have a procedure for central line insertion? ☐ YES ☐ NO










☐ NHSN Surveillance and monitoring

☐ Project Joints

☐ Surgical safety checklist

☐ CHG shower and prep

☐ Implementation of standardized guidelines to ensure use of basic aseptic techniques

☐ Temperature regulation for all surgical procedures

☐ Blood glucose control in all surgical patients

☐ Standardized antibiotic administration order sets for each surgical procedures

☐ Adherence to catheter removal protocol – removal within 24-48 hours postop

☐ Integration of PFE in SSI prevention activities/education

☐ Other:


☐ Lean

☐ TeachBack

☐ TeamSTEPPS

☐ Other:

Surgical Site Infections (SSI)






☐ Leadership


☐ Data

☐ Other :

☐ QIN/QIO






☐ Other: Does your facility have a policy for infection prevention in the operating room (OR)?

☐ YES ☐ NO

Does your facility have any procedures related to infection prevention in the OR?

☐ YES ☐ NO




☐ This section does not apply to my facility






☐ Implementation of ventilator bundle

☐ NHSN surveillance and monitoring

☐ Integration of PFE in VAE prevention activities/education

☐ Implementation of CUSP 4 MVP strategies

☐ Elevate head of bed

☐ Spontaneous awakening trials

☐ Spontaneous breathing trials

☐ Oral care every 2 hours with chlorhexidine

☐ Daily early and progressive mobility

☐ Use of delirium assessments

☐ Use of low tidal volume ventilation

☐ Enhanced nurse to nurse and interdisciplinary communication

☐ Other:


☐ Lean

☐ TeachBack

☐ TeamSTEPPS

☐ Other:



Ventilator-asscoiated Event (VAE)




☐ Leadership


☐ Data

☐ Other:

☐ QIN/QIO






☐ Other:

Does your facility have a policy for the prevention of VAE? ☐ YES ☐ NO

Does your facility have a procedure for mechanical ventilation? ☐ YES ☐ NO









☐ Medication reconciliation

☐ EMR integration – use of alerts and hard stops, such as INR hard stop

☐ Implementation of a post discharge med reconciliation program

☐ Include pharmacist as part of quality team

☐ Basal bolus insulin protocol

☐ Development and implementation of anticoagulation protocol

☐ Completion of ISMP self-assessment

☐ NCC-MERP error classification system

☐ Implementation of ADE trigger system or surveillance system

☐ Physician and pharmacy education and engagement

☐ Implementation of Opioid Overdose prevention toolkit

☐ Use of surveillance systems to monitor opioid use/abuse

☐ Development of opioid prescribing protocols/guidelines

☐ Integration of PFE in ADE prevention activities and education

☐ Other:


☐ Lean

☐ TeachBack

☐ TeamSTEPPS

☐ Other:

Adverse Drug Events (ADE)






☐ Leadership


☐ Data

☐ Other:

☐ QIN/QIO






☐ Other:

Does your facility have a policy for ADE? ☐ YES ☐ NO

Does your facility have a procedure for ADE? ☐ YES ☐ NO

Does your facility have an anticoagulation policy that addresses INR >5? ☐ YES ☐ NO









☐ Risk assessment on admission and upon change in status

☐ Patient and family education and engagement

☐ Standardized interventions for fall risk

☐ Customized interventions for high risk patients

☐ Use of multidisciplinary team to design and implement facility wide fall prevention program.

☐ Post fall huddles as well as root cause analysis of all falls

☐ Integration of PFE in fall prevention activities

☐ Other:


☐ Lean

☐ TeachBack

☐ TeamSTEPPS

☐ Other:



Falls & Immobility





☐ Leadership


☐ Data

☐ Other:

☐ QIN/QIO






☐ Other:

Does your facility have a policy for Falls and Immobility? ☐ YES ☐ NO

Does your facility have a procedure for Falls and Immobility? ☐ YES ☐ NO








☐ Admission risk assessment for all patients

☐ Reassessment of risk for all patients daily and upon change in status

☐ Pressure ulcer prevention bundle for high risk patients

☐ Daily skin inspections

☐ Management of moisture

☐ Optimize nutrition and hydration

☐ Minimize pressure

☐ Integration of PFE in pressure ulcer prevention activities/education

☐ Other:


☐ Lean

☐ TeachBack

☐ TeamSTEPPS

☐ Other:



☐ Leadership

Pressure Ulcers






☐ Data

☐ Other:

☐ QIN/QIO






☐ Other:

Does your facility have a policy for Pressure Ulcers? ☐ YES ☐ NO

Does your facility have a procedure for Pressure Ulcers? ☐ YES ☐ NO








☐ Admission risk assessment for all patients

☐ Provide appropriate VTE prophylaxis based on standardized national guidelines

☐ Provide discharge instructions for all patients at risk for VTE

☐ Integration of PFE in VTE prevention activities/education

☐ Physician and pharmacy education and engagement

☐ Other:


☐ Lean

☐ TeachBack

☐ TeamSTEPPS

☐ Other:



☐ Leadership


Venous Thromboembolism (VTE)





☐ Data

☐ Other:

☐ QIN/QIO






☐ Other:

Does your facility have a policy for the prevention of VTE? ☐ YES ☐ NO

Does your facility have a procedure for VTE prevention? ☐ YES ☐ NO








☐ Hand hygiene compliance program and monitoring

☐ Implementation of C. diff reduction bundle

☐ Enhanced surveillance and monitoring, within the hospital setting as well as the surrounding community

☐ Education and implementation of appropriate environmental cleaning techniques

☐ Implementation of ED and OR cleaning procedures

☐ Development and implementation of Antimicrobial stewardship program

☐ Integration of PFE in CDI prevention activities/education

☐ Other:


☐ Lean

☐ TeachBack

☐ TeamSTEPPS

☐ Other:


Clostridium Difficile (C. Diff)






☐ Leadership


☐ Data

☐ Other:

☐ QIN/QIO






☐ Other:

Does your facility have a policy for C. diff prevention? ☐ YES ☐ NO

Does your facility have a procedure for C. diff prevention? ☐ YES ☐ NO








☐ Use of early detection sepsis screening tool in inpatient units as well as ED

☐ EMR integration – use of alerts

☐ Implementation of Surviving Sepsis campaign bundle

☐ Use of 3 and 6-hour sepsis bundles

☐ Development of standardized order sets for care

☐ Utilize modified early warning score (MEWS) system with existing sepsis bundle to facilitate identification of sepsis

☐ Other:


☐ Lean

☐ TeachBack

☐ TeamSTEPPS

☐ Other:



☐ Leadership


Sepsis





☐ Data

☐ Other:

☐ QIN/QIO






☐ Other:

Does your facility have a policy for Sepsis recognition and treatment? ☐ YES ☐ NO

Does your facility have a procedure for Sepsis treatment/management? ☐ YES ☐ NO









☐ Hand hygiene compliance program and monitoring

☐ Enhanced surveillance and monitoring of resistant organisms

☐ Education and implementation of appropriate environmental cleaning techniques

☐ Adherence to isolation precautions

☐ Utilization of decolonization strategies, where appropriate, to eradicate carriage of organism

☐ Implementation of ED and OR cleaning procedures

☐ Development and implementation of Antimicrobial stewardship program

☐ Integration of PFE in MDRO prevention activities/education

☐ Other:


☐ Lean

☐ TeachBack

☐ TeamSTEPPS

☐ Other:





Multi Drug Resistant Organism (MDRO)



☐ Leadership


☐ Data

☐ Other:

☐ QIN/QIO






☐ Other:

Does your hospital have an antimicrobial stewardship program in place? ☐ YES ☐ NO









☐ Implementation of exposure control plan designed to eliminate or minimize worker exposure blood borne pathogens

☐ Use of devices with safety features engineered to prevent sharps injuries

☐ Implementation of sharps injury prevention plan

☐ Implementation of timely post exposure management plan

☐ WSHA Safe Patient handling

☐ Use of safe patient handling checklist on all direct patient care units

☐ Employee education regarding ergonomics and back safety

☐ Other:


☐ Lean

☐ TeachBack

☐ TeamSTEPPS

☐ Other:


Worker Safety






☐ Leadership


☐ Data

☐ Other:

☐ QIN/QIO






☐ Other:

Does your facility have a policy for safe patient handling? ☐ YES ☐ NO

Does your facility have a sharps injury prevention plan? ☐ YES ☐ NO









☐ Promote safe use of medical imaging devices

☐ Promotion of Choosing Wisely campaign tools

☐ Implementation of hospital wide imaging protocols

☐ Standardized dosing policies establishing use of lowest effective dose

☐ Implementation of strategies for monitoring and tracking radiologic dose exposure

☐ Integration of PFE strategies in reducing radiation exposure

☐ Other:


☐ Lean

☐ TeachBack

☐ TeamSTEPPS

☐ Other:



Undue Exposure to Radiation





☐ Leadership


☐ Data

☐ Other:

☐ QIN/QIO






☐ Other:

Does your facility have a policy for collecting data on the total amount of radiation delivered to

a patient during a CT scan? ☐ YES ☐ NO

Does your facility have a procedure for collecting total amount of radiation delivered during CT

scans? ☐ YES ☐ NO









☐ Hard-stop policy for non-medically indicated deliveries (induction and C-section)

☐ Induction/C-section scheduling process

☐ Physician leadership of hard-stop policy and scheduling process

☐ Protocols for the diagnosis and management of obstetric hemorrhage

☐ RRT for obstetric emergencies

☐ Implementation of MEWS (Maternal Early Warning Signs)

☐ Guidelines and/or protocols for early recognition and response to preeclampsia

☐ Perform drills/simulations for obstetric emergencies

☐ Other:


☐ Lean

☐ TeachBack

☐ TeamSTEPPS

☐ Other:



Obstetrical Adverse Events




☐ Leadership


☐ Data

☐ Other:

☐ QIN/QIO






☐ Other:



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