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Hospital-Associated Infections Data NUR630

Hospital-Associated Infections Data NUR630

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.

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

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Nursing 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:

  1. What conclusions can be drawn for each quality measure over the 5-year period?
  2. What trends do you see for each quality measure over the 5-year period?
  3. When comparing each quality measure, is the quality measure better than, worse than, or no different from the national benchmark over time?
  4. Based on your examination of the data, which of the quality measures should you prioritize and why?
  5. Develop a quality improvement metric and related measures to improve care processes, outcomes, and the patient experience relating to the identified area of opportunity.
  6. 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.

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.

Hospital-Associated Infections Data NUR630 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

Continuous Quality Improvement in Health Care

Review Chapter 4 in Continuous Quality Improvement in Health Care.

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.

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

Serious Reportable Events

Explore the Serious Reportable Events page located on the National Quality Forum website.

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)

… 

Medicare Initiatives Improve Hospital Care, Patient Safety

Read “Medicare Initiatives Improve Hospital Care, Patient Safety,” by Conway, from The Hospitalist (2015).

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

… 

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

… 

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

… 

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

… 

Benchmark – Hospital-Associated Infections Data – Rubric

Rubric Criteria

Conclusions

Criteria Description

Conclusions

5. Target

9.6 points

Conclusions that can be drawn for each quality measure over the 5-year period are appropriate. The conclusions are supported by the data.

4. Acceptable

8.83 points

Conclusions that can be drawn for each quality measure over the 5-year period are appropriate. The conclusions are mostly supported with data.

3. Approaching

8.45 points

Conclusions that can be drawn for each quality measure over the 5-year period are present.

2. Insufficient

7.68 points

Conclusions that can be drawn for each quality measure over the 5-year period are present, but the conclusions are not supported with data.

1. Unsatisfactory

0 points

Conclusions that can be drawn for each quality measure over the 5-year period are not present.

Trends

Criteria Description

Trends

5. Target

9.6 points

A description of the trends that can be seen in the data is present. The trends discussed are accurate.

4. Acceptable

8.83 points

A description of the trends that can be seen in the data is present. The trends discussed are mostly accurate. Hospital-Associated Infections Data NUR630

3. Approaching

8.45 points

A description of the trends that can be seen in the data is present.

2. Insufficient

7.68 points

A description of the trends that can be seen in the data is present, but lacks detail or is incomplete.

1. Unsatisfactory

0 points

A description of the trends that can be seen in the data is not present.

Quality Measure and National Benchmarks

Criteria Description

Quality Measure and National Benchmarks

5. Target

7.2 points

A comparison of each quality measure to the national benchmark is present and all comparisons are accurate.

4. Acceptable

6.62 points

NA

3. Approaching

6.34 points

NA

2. Insufficient

5.76 points

A comparison of each quality measure to the national benchmark is present, but some comparisons are not accurate. Hospital-Associated Infections Data NUR630

1. Unsatisfactory

0 points

A comparison of each quality measure to the national benchmark is not present.

Prioritization of Quality Measures

Criteria Description

Prioritization of Quality Measures

5. Target

7.2 points

Prioritization of the quality measures is present and is appropriate based on the data.

4. Acceptable

6.62 points

NA

3. Approaching

6.34 points

NA

2. Insufficient

5.76 points

Prioritization of the quality measures is present, but is not appropriate based on the data.

1. Unsatisfactory

0 points

Prioritization of Quality Measures

Quality Improvement Metric

Criteria Description

Quality Improvement Metric

5. Target

7.2 points

A quality improvement metric is present and thorough. The metric is appropriate for the quality measure.

4. Acceptable

6.62 points

A quality improvement metric is present and detailed. The metric is mostly appropriate for the quality measure.

3. Approaching

6.34 points

A quality improvement metric is present.

2. Insufficient

5.76 points

A quality improvement metric is present, but some portions may not be appropriate for the quality measure.

1. Unsatisfactory

0 points

A quality improvement metric is not present.

Monitoring the Quality Improvement Metric (B)

Criteria Description

Monitoring the Quality Improvement Metric (C6.6)

5. Target

7.2 points

An explanation of how to monitor the metric and related measures to improve care processes, outcomes, and the patient experience is present and thorough.

4. Acceptable

6.62 points

An explanation of how to monitor the metric and related measures to improve care processes, outcomes, and the patient experience is present and detailed.

3. Approaching

6.34 points

An explanation of how to monitor the metric and related measures to improve care processes, outcomes, and the patient experience is present.

2. Insufficient

5.76 points

An explanation of how to monitor the metric and related measures to improve care processes, outcomes, and the patient experience is present, but lacks detail or is incomplete.

1. Unsatisfactory

0 points

An explanation of how to monitor the metric and related measures to improve care processes, outcomes, and the patient experience is not present.

Presentation of Content

Criteria Description

Presentation of Content

5. Target

36 points

The content is written clearly and concisely. Ideas universally progress and relate to each other. The project includes motivating questions and advanced organizers. The project gives the audience a clear sense of the main idea.

4. Acceptable

33.12 points

The content is written with a logical progression of ideas and supporting information exhibiting a unity, coherence, and cohesiveness. Includes persuasive information from reliable sources.

3. Approaching

31.68 points

The presentation slides are generally competent, but ideas may show some inconsistency in organization or in their relationships to each other.

2. Insufficient

28.8 points

The content is vague in conveying a point of view and does not create a strong sense of purpose. Includes some persuasive information.

0 points

The content lacks a clear point of view and logical sequence of information. Includes little persuasive information. Sequencing of ideas is unclear.

Layout

Criteria Description

Layout

5. Target

12 points

The layout is visually pleasing and contributes to the overall message with appropriate use of headings, subheadings, and white space. Text is appropriate in length for the target audience and to the point. The background and colors enhance the readability of the text.

4. Acceptable

11.04 points

The layout background and text complement each other and enable the content to be easily read. The fonts are easy to read and point size varies appropriately for headings and text.

3. Approaching

10.56 points

The layout uses horizontal and vertical white space appropriately. Sometimes the fonts are easy to read, but in a few places the use of fonts, italics, bold, long paragraphs, color, or busy background detracts and does not enhance readability.

2. Insufficient

9.6 points

The layout shows some structure, but appears cluttered and busy or distracting with large gaps of white space or a distracting background. Overall readability is difficult due to lengthy paragraphs, too many different fonts, dark or busy background, overuse of bold, or lack of appropriate indentations of text.

1. Unsatisfactory

0 points

The layout is cluttered, confusing, and does not use spacing, headings, and subheadings to enhance the readability. The text is extremely difficult to read with long blocks of text, small point size for fonts, and inappropriate contrasting colors. Poor use of headings, subheadings, indentations, or bold formatting is evident.

Language Use and Audience Awareness (includes sentence construction, word choice, etc.)

Criteria Description

Language Use and Audience Awareness (includes sentence construction, word choice, etc.)

5. Target

12 points

The writer uses a variety of sentence constructions, figures of speech, and word choice in distinctive and creative ways that are appropriate to purpose, discipline, and scope.

4. Acceptable

11.04 points

The writer is clearly aware of audience, uses a variety of appropriate vocabulary for the targeted audience, and uses figures of speech to communicate clearly.

3. Approaching

10.56 points

Language is appropriate to the targeted audience for the most part.

2. Insufficient

9.6 points

Some distracting inconsistencies in language choice (register) or word choice are present. The writer exhibits some lack of control in using figures of speech appropriately.

1. Unsatisfactory

0 points

Inappropriate word choice and lack of variety in language use are evident. Writer appears to be unaware of audience. Use of primer prose indicates writer either does not apply figures of speech or uses them inappropriately.

Mechanics of Writing (includes spelling, punctuation, grammar, language use)

Criteria Description

Mechanics of Writing (includes spelling, punctuation, grammar, language use)

5. Target

6 points

Writer is clearly in control of standard, written, academic English.

4. Acceptable

5.52 points

Slides are largely free of mechanical errors, although a few may be present.

3. Approaching

5.28 points

Some mechanical errors or typos are present, but they are not overly distracting to the reader.

2. Insufficient

4.8 points

Frequent and repetitive mechanical errors distract the reader.

1. Unsatisfactory

0 points

Slide errors are pervasive enough that they impede communication of meaning.

Documentation of Sources

Criteria Description

Documentation of Sources (citations, footnotes, references, bibliography, etc., as appropriate to assignment and style)

5. Target

6 points

Sources are completely and correctly documented, as appropriate to assignment and style, and format is free of error.

4. Acceptable

5.52 points

Sources are documented, as appropriate to assignment and style, and format is mostly correct.

3. Approaching

5.28 points

Sources are documented, as appropriate to assignment and style, although some formatting errors may be present.

2. Insufficient

4.8 points

Documentation of sources is inconsistent or incorrect, as appropriate to assignment and style, with numerous formatting errors.

1. Unsatisfactory

0 points

Sources are not documented.

Total120 points

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