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Culture Exchange: NHSN Data Quality QIA

Aim of the project
Improve communication between dialysis facility and hospitals to retrieve information about the positive blood cultures (PBC) identified in hospitals
Improve the reporting of positive blood cultures to NHSN for the dialysis patients identified on the 1st and 2nd day of hospital admission

Project Goal
Achieve a 2% improvement over baseline in the reposting rate of PBC identified in the hospitals by June 2017
Baseline data period used for the baseline rate: January 2016 to June 2016 (from NHSN)
Re-measure rate (goal rate) comes from : January 2017 to June 2017 (from NHSN)

Project requirements
Attend and / or view the Culture exchange NHSN data Quality QIA Introductory Webinar and complete the Webinar attestation form by December 15, 2016
Complete the RCA via Survey Monkey by December 19, 2016
Based on the results of the RCA, Network staff will work with every facility individually to develop an action plan and this will start in the 1st week of January 2017
Attend the Community Coalition meetings hosted by TMF Quality Innovation Network

Monthly Monitoring Activities
Network will track facility’s BSI reporting rate via NHSN
Facilities will be required to mail in the patient log (hospitalized and patients that missed treatments for the month) to the Network
Network will evaluate the NHSN data for improvements in BSI reporting
Facilities that fail to show improvement in BSI reporting by first quarter of 2017 will implement RCI to facilitate increase reporting of BSI identified in hospitals

Activities after June 2017
Facilities will be monitored every quarter after June 2017 until 2020 for sustained increase in reporting of PBC identified in hospitals

Culture Exchange: NHSN Data Quality QIA Summary


Online RCA via Survey Monkey due by December 19, 2016
PDSA Worksheet [ con type=docx]

Monthly Patient Logs

January 2017 Patient Log  due by March 15, 2017
February 2017 Patient Log  
due by March 15, 2017
March 2017 Patient Log  
due by April 21, 2017
April 2017 Patient Log  
due by May 15, 2017
May 2017 Patient Log 
due by June 15, 2017  
June 2017 Patient Log 
due by July 14, 2017