CPQCC/CSS NICU CLABSI Prevention

About 50 NICUs joined the CCS NICU CLABSI Prevention 2013 Project which was a Quality Improvement Initiative jointly sponsored by CCS, CPQCC and CAN. 
White Paper:  Provider-Preventable Conditions Including Health Care-AcquiredConditions (HCAC); Neonatal/Pediatric Reporting and Payment Adjustment (956.8 KB  )
Quick Links:
          Project Communications
          Change Package:  Sources
          Learning Session #1:  Handouts

Project Communications
Welcome Letter - December 10, 2012 (70.2 KB  )
NCABSI Hospital Start-up Kit and Site Guide - October 24, 2011 (356.6 KB  )
CLABSI Reduction Project Letter - January 15, 2013 (64.7 KB  )
Insertion Information (93.1 KB  )
Maintenance Information (55.6 KB  )
CDC Central Line-Associated Bloodstream Infection (CLABSI) Event 
(734.3 KB  )
March Letter (32.9 KB  )
Webinar Materials - May 2, 2013 
o    NICU Health Care Failure Modes and Effect Analysis (FMEA) - Balagi Govindaswami, MD, MPH (100.7 KB  )
o    Applying the CUSP Model to a Clinical Improvement Project - Mary Nennig, BSN, RN(17.7 KB  )
o    NICU CLABSI Central Line Maintenance Information - LAC-USC (20.5 KB  )
o    Central Lines Data Collection Form 2013 - KP-LAMC (102 KB  ) 
o    Line Maintenance 2013 - KP-LAMC (38 KB  )
o    DMC/NCABSI Central Line Maintenance Information (18.6 KB  )
o    NICU Central Line Insertion Practices Adherence Monitoring (35.4 KB  )
Webinar Materials - May 30, 2013 
o    What Makes a Good Checklist? - Joseph Schulman, MD (156.6 KB  )
o    CUSP Update - Mary Nennig (1.4 MB  )
o    Staff Safety Assessment (for CUSP) (199.5 KB  )
o    Sharp Mary Birch Presentation - Linda Salinda (233.1 KB  )
Webinar Materials - June 27, 2013
o    Kaiser Permanente Hayward Medical Center Presentation - Melinda Porter, Cindy Wikler(1 MB  )
o    CUSP Update - Mary Nennig (1.3 MB  )
Webinar Materials - August 8, 2013
o    CUSP Update - Mary Nennig (1.4 MB  )
o    Understanding Michigan - Jeff Schulman, MD (118.2 KB  )
Webinar materials - October 3, 2013
o    NorthBay Excel Documentation tool (22.5 KB  )
Learning session materials - October 30, 2013
o    LS #2 agenda (16.9 KB  )
o    A1-CHOC presentation (139.4 KB  )
o    A3-KWH presentation (190.2 KB  )
o    A4-Good Sam presentation-A (127.8 KB  )
o    A5-UCSF presentation (1.4 MB  )
o    A6-CHLA (614.6 KB  )
o    B-HSOPS 10.30.13-MNennig (554.7 KB  )
o    B-NCABSI Hazard Functions (153.4 KB  )
o    C-Future of QI (153.4 KB  )
o    C-SPC handout (4.9 MB  )
Change Package:  Sources
Switch: How to Change Things When Change Is Hard by Chip and Dan Heath. The first chapter is available here for free - it summarizes the main arguments in the book. Also valuable: The Switch Framework [PDF] and Switch for Organizations: The Workbook [PDF].  Available at: http://www.heathbrothers.com/resources/
Side tracks on the safety express. Interruptions lead to errors and unfinished...wait, what was I doing? ISMP Medication Safety Alert! Acute Care Edition. November 29, 2012;17:1-3. Available at: http://www.psnet.ahrq.gov/resource.aspx?resourceID=25472
Do Prolonged Peripherally Inserted Central Venous Catheter Dwell Times Increase the Risk of Bloodstream Infection? Milstone, Sengupta, Infection Control and Hospital Epidemiology, Vol. 31, No. 11 (November 2010), pp.1184-1187
Moving toward Elimination of Healthcare‐Associated Infections: A Call to Action. Cardo, D; et al Infection Control and Hospital Epidemiology, Vol. 31, No. 11 (November 2010), pp. 1101-1105
Engineering a Learning Healthcare System. A Look at the Future. Institute of Medicine (US) and National Academy of Engineering (US) Roundtable on Value & Science-Driven Health Care. Washington (DC): National Academies Press (US); 2011. Free PDF of book available at: http://www.ncbi.nlm.nih.gov/books/NBK61965/
Using Healthcare Failure Modes and Effects AnalysisSM.  Available at:http://www.patientsafety.gov/SafetyTopics/HFMEA/HFMEA_JQI.html
Healthcare Failure Mode and Effect Analysis (HFMEATM) Videoconference Course presented by VA National Center for Patient Safety.  Available at:http://www.patientsafety.gov/SafetyTopics/HFMEA/HFMEAmaterials.pdf
Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011.  Available at:http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf
Associated CDC checklist available at: http://www.ahrq.gov/cusptoolkit/ (Look for link: CDC Checklist for Prevention of Central Line-Associated Blood Stream Infections)
AHRQ: Using a Comprehensive Unit-based Safety Program to Prevent Healthcare-Associated Infections. This page provides an overview of CUSP and links to useful resources on the Web. Available at: http://www.ahrq.gov/qual/cusp.htm
AHRQ CUSP toolkit. Follow the links for each toolkit module; you will be led to corresponding presentation slides, facilitator notes, and videos.  Available at: http://www.ahrq.gov/cusptoolkit/
You also can download all CUSP toolkit components (and there are many!) here:http://www.ahrq.gov/cusptoolkit/download.htm
How to use the CUSP toolkit.  Available here:  http://www.ahrq.gov/cusptoolkit/usetoolkit.htm, and http://www.ahrq.gov/cusptoolkit/videos/01a_intro/
CUSP Toolkit Apply CUSP, Facilitator Notes.  Available here: http://www.ahrq.gov/cusptoolkit/7applycusp/facapplycusp.htm
AHRQ Annual Conference 2012 Press Briefing on CLABSI, CUSP Toolkit.  Available here: http://www.ahrq.gov/about/annualconf12/video/clabsicusp/
On the CUSP Stop HAI - CLABSI Toolkit
http://onthecuspstophai.org/wp-content/uploads/2012/04/CLABSI_Toolkit.doc
Evaluating the Processes of Neonatal Intensive Care: Thinking Upstream to Improve Downstream Outcomes
http://www.wiley.com/WileyCDA/WileyTitle/productCd-0727918338.html 

To help evaluate the impact of your NICU engaging with CUSP and other activities we’ll conduct during this project, we strongly encourage your NICU administer the AHRQ Hospital Survey on Patient Safety Culture at the beginning of this project period and at the end of the project year: http://www.ahrq.gov/qual/patientsafetyculture/hospsurvindex.htm
National Healthcare Safety Network (NHSN) Report, Data Summary for 2011, Devise-asociated Module (1.1 MB  )
CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011.  Available at:  www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf (1 MB  )

Learning Session #1: Handouts
Learn from Defects Tool (217 KB  )
The Comprehensive Unit-Based Safety Program:  A Model for Prevention and Sustainability in Healthcare (1 MB  )
Decisions, Decisions...Time for Us to Map Out How We'll Learn from Our Experience(180.5 KB  )
Hospital Survey on Patient Safety Culture (147.1 KB  )
Fine-grained Understanding of the Daily Work of the NICU to Sustain CLABSI Prevention(1.4 MB  )
NCABSI - Participation, Website and Data Reporting (957.3 KB  )
NICU Health Care Failure Modes and Effect Analysis (FMEA)  (119.1 KB  )