Aligning Forces for Quality: Transforming Care at the

Bedside

Data Template Training

Kathy Vezina

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Overview of TCAB

Potential Voluntary Measure & High Leverage Changes

Patient & Family Centered Care

Workplace & Team Vitality Safety & Reliability Value-added Care

•Patients report their pain is always well controlled great than 95% of the time.

•Patients are Willing to Recommend the Hospital Greater than 95% of the Time

•Involve Patients & Families on Advisory Groups

•Reduced Voluntary RN Turnover

•Improved Staff Satisfaction

•Create Front-Line Teams with the Authority to Act & Transform Care at the Bedside

•Develop Early Response Systems

•Improve Patient Handoff

•Increase RN Time in Direct Patient Care Greater Than 50%

•Improve Workflow in Admission and Discharge Process.

Required Measures

Patient fallsFalls with

harmPressure ulcer

prevalence

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Required Measure: Patient Falls

• Fall is defined as an unplanned descent to the floor.

• Numerator: Number of inpatient falls on the unit.

• Denominator: Total number of inpatient days on unit.

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Required Measure: Falls with Harm

• Falls with harm is defined as minor (results in application of dressing, ice, cleaning of a wound, limb elevation, or topical medication), moderate (results in suturing, steri-strips, fracture, or splinting), major (surgery, casting, or traction), or death (as a result of the fall).

• Numerator: Two separate numerators are to be reported separately: Number of inpatient falls and number of inpatient falls with injuries on the unit.

• Denominator: Total number of inpatient days on unit.

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Required Measure: Pressure Ulcer Prevalence

• Hospital Acquired Pressure Ulcer (Nosocomial) is defined as new ulcer(s) developed after admission to a facility. All pressure ulcers not meeting the community-acquired criteria should be designated as hospital-acquired pressure ulcers. Pressure ulcer is defined as localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction.

• Numerator: Number of pressure ulcers developed using the National Advisory Panel (NPUAP)-Stage II or greater (II-IV+ eschar) for hospital-acquired pressure ulcers.

• Denominator: Total number of inpatient days on unit.

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Required Measures:Frequency and Reporting

• Frequency: Monthly on the TCAB unit.• Reporting: The data collection spreadsheet

provided to the unit will have cells to enter inpatient days on the unit, number of falls, number of falls with harm, and pressure ulcers. The rate will be calculated in the spreadsheet.

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Race, ethnicity and language categoriesRace• Black• White• Asian• American

Indian/Alaska Native• Native Hawaiian/

Pacific Islander• Multiracial*• Declined*• Unavailable*

*This designation indicates a modification to the OMB R/E categories

Ethnicity• Hispanic• Not Hispanic• Declined*• Unavailable*

Language•English•Spanish•Other•Declined •Unavailable

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Race definitionsBlack or African American: Person having origins in any of the black racial groups of Africa; include terms such as “Haitian,” “Dominican,” or “Somali.”

White: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Asian: Person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

American Indian or Alaska Native: Person having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment.

Native Hawaiian or Other Pacific Islander: Person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

Multiracial*: A person having more than one or a combination of the above origins.

Declined*: Patient is unwilling to choose a race category or cannot identify him/herself with one of the listed races.

Unavailable*: Patient is physically unable to respond.*This designation indicates a modification to the OMB R/E categories

Source: HRET Toolkit, http://www.hretdisparities.org/ accessed on Sept 16, 2009

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Ethnicity definitions

Hispanic or Latino: Person of Cuban, Mexican, Puerto Rican, South or Central American decent, regardless of race.

Non-Hispanic or Latino: Person not of Hispanic or Latino ethnicity.

Declined*: Patient is unwilling to provide an answer to the ethnicity question or cannot identify him/herself as Hispanic or Not Hispanic.

Unavailable*: Patient is physically unable to respond.

*This designation indicates a modification to the OMB R/E categories

Source: HRET Toolkit, http://www.hretdisparities.org/ accessed on Sept 16, 2009

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Language DefinitionsEnglish: English is the language identified by the patient for speaking to health care providers or reading health care information.

Spanish: Spanish is the language identified by the patient for speaking to health care providers or reading health care information.

Other: Any stated language other than English or Spanish.

Declined: A person who is unwilling to state a language preference.

Unavailable: Patient is physically unable to respond.

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Questions?

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Let’s walk through the data template…

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When Entering Data

• Double check that your hospital name appears on the spreadsheets before submitting.

• Check that all data checks are highlighted GREEN; if data checks are in RED, make sure to correct your data before submitting it.

• Leave zeros in the cells with no data.

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Questions?