Draft Project Charter Eliminating HAI's - Patientsafetycouncil.org

Population
Preventing HAI’s can reduce patient progressing to morbidity, increased LOS and death
Coding based on MD diagnosis HAI (use any available codes for VAP, CLABSI & CAUTI)
C Diff may an HAI of interest to ‘further’ target
Dioalysis patients may be a target that could have significant benefit
• Most MDs identify infection but not necessarily HA
• Providers not aware of documenting POA infections
• Patient admitted into hospital without infection?
• N = all patients with ‘preventable’ HAI (VAP, CLABSI, CAUTI)
• D = device days/1000 (as per NHSN standard reporting)
Goal
• Reduce the incidence of HAI’s in the acute care patient to near zero across the county;
• Need current number – administrative data – for Not Present on Admission
• Side goal: Reduce costs and LOS for patients requiring certain devices.
• Each organization: rate of VAP, CLABSI, CAUTI not POA
How can this project help us at our facility?
• Implementation tools, ideas and methods sharing can accelerate change and impact
Elevator Speech
Recommend producing an elevator speech for each target audience.
• What our project is about… prevention of the HAI’s (VAP, CLABSI & CAUTI and/or C Diff) to near zero in
our region, as well as improving overall patient outcomes.
• Why it is important to do… because HAI’s are preventable with appropriate intervention, yet today it
occurs in about 1.7million per year in the US, killing 99K. That’s …. patients getting HAI’s in our region per
day, and … dying from them.
• What success will look like… increased regional compliance with evidenced-based best practices
resulting in zero ‘preventable’ HAI’s, and institutions realizing an overall decrease in patient hospital stay
and costs.
• What we need from you… a commitment to understand, support, and comply with best practices to
prevent HAI’s including early identification of high-risk patients, collaborating with colleagues, and providing
best possible data and classification of HAI’s.
Staging Project
Considering evidence available it’s clear what needs to be done…
Timeline
Description
Feb 2011 • Where are we now with CLABSI, VAP and CAUTI
• How to prevent HAI’s?
• Literature and Tools available
• Are C-Diff and SSI’s important to us? How does antibiotic stewardship play a role?
April 2011 • HAI prevention campaigns
• Order sets available in most facilities
• Change management/Implementation
June 2011 • Prevention and surveillance methods, tools and resources
August 2011 • Finalize Toolkit
• Review change management
October 2011 • Measurement of progress
• Stakeholder analysis
December 2011 • Project status evaluation