Benchmark – Hospital-Associated Infections Data

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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/ Assignment

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.

Create a 12-15-slide PowerPoint (not including title and reference slides) presenting the data to the stakeholders. Address the following in your PowerPoint:

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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.

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.

RUBRIC

. Benchmark –

Hospital-Associated Infections Data

– Rubric
Hospital-Associated Infections Data

Conclusions

9.

6 points

Trends

9.6 points

Quality Measure and National Benchmarks

7.2 points

Prioritization of Quality Measures

7.2 points

Quality Improvement Metric

7.2 points

Monitoring the Quality Improvement Metric (B)

7.2 points

Presentation of Content

36 points

Layout

12 points

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

12 points

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

6 points

Documentation of Sources

6 points

Total 120 points

Sheet1

ABC Health

1/1/15 9/30/15

3.422

ABC Health

1/1/15 9/30/15

ABC Health

1/1/15 9/30/15

ABC Health Surgical Site Infection from colon surgery (SSI: Colon) HAI_3_SIR

ABC Health Central line-associated blood stream infections (CLABSI) HAI_1_SIR 1/1/14 12/31/14

3.063

ABC Health Catheter-Associated Urinary Tract Infections (CAUTI) HAI_2_SIR 1/1/14 12/31/14

ABC Health Surgical Site Infection from abdominal hysterectomy (SSI: Hysterectomy) HAI_4_SIR 1/1/14 12/31/14

ABC Health Surgical Site Infection from colon surgery (SSI: Colon) HAI_3_SIR

2.219

ABC Health Central line-associated blood stream infections (CLABSI) HAI_1_SIR 3/1/13 11/30/13

ABC Health Catheter-Associated Urinary Tract Infections (CAUTI) HAI_2_SIR 3/1/13 11/30/13

Not available

ABC Health Surgical Site Infection from abdominal hysterectomy (SSI: Hysterectomy) HAI_4_SIR 3/1/13 11/30/13

2.094

ABC Health Surgical Site Infection from colon surgery (SSI: Colon) HAI_3_SIR

ABC Health Central line-associated blood stream infections (CLABSI) HAI_1_SIR 1/1/12 12/31/12

ABC Health Catheter-Associated Urinary Tract Infections (CAUTI) HAI_2_SIR 1/1/12 12/31/12

0.827

ABC Health Surgical Site Infection from abdominal hysterectomy (SSI: Hysterectomy) HAI_4_SIR 1/1/12 12/31/12

2.132

ABC Health Surgical Site Infection from colon surgery (SSI: Colon) HAI_3_SIR

ABC Health Central line-associated blood stream infections (CLABSI) HAI_1_SIR 1/1/11 12/31/11 2.234

ABC Health Catheter-Associated Urinary Tract Infections (CAUTI) HAI_2_SIR 1/1/11 12/31/11

ABC Health Surgical Site Infection from abdominal hysterectomy (SSI: Hysterectomy) HAI_4_SIR 1/1/11 12/31/11

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 1/1/15 9/30/15 2.548 3.555
Central line-associated blood stream infections (CLABSI) HAI_1_SIR 3.422
Catheter-Associated Urinary Tract Infections (CAUTI) HAI_2_SIR 1.231 0.466
Surgical Site Infection from abdominal hysterectomy (SSI: Hysterectomy) HAI_4_SIR 2.703 4.608
1/1/14 12/31/14 2.319 2.487
3.063
1.089 0.567
2.512 3.697
3/1/13 11/30/13 2.219
3.128 3.062
Not available 4 – Data suppressed by CMS for one or more quarters.
2.094
1/1/12 12/31/12 2.136 0.174
2.089 2.203
0.827
2.132
1/1/11 12/31/11 2.234 0.273
2.845
1.879 2.814
2.133 1.148

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