Patient Safety: Healthcare- Associated Infection

Quality Improvement Activities

For questions and comments, please contact:
Sarah Keehner,
Quality Improvement Director
(203) 285-1214

Heather Camilleri, CCHT
Quality Improvement Coordinator
(203) 285-1224
QIA Facilities:

List of facilities

participating in the Bloodstream Reduction QIA


List of facilities participating in Long Term Catheter Reduction QIA to be announce when data because available.



Please be aware of the dates associated with each activity.


Provide: Input Key Facility Staff Contact Information into the Patient Safety: Healthcare-Associated Infection collection tool by Friday, February 2, 2018. One contact form per facility.

Watch:  View the "Five Whys Jefferson Memorial Example" Video (<2 minutes)
DISCUSS: Talk with dialysis team members and patients to identify root causes of barriers to increasing utilization of home dialysis.
COMPLETE: Answer questions in the Patient Safety HAI QIA Root Cause Analysis (RCA) Reporting Tool by Friday, February 9, 2018. One assessment per facility.

ATTEND: Join us for the Patient Safety: Healthcare-Associated Infections QIA Kick-Off Webinar to be held on Thursday, February 15, 2018 from 1:00-1:30 PM.  Project requirements, activities to augment current process, and Q&A session will be available during this webinar. 
Click here to register.

Dear Provider,
 IPRO End Stage Renal Disease (ESRD) Network of New England would like to notify facilities of a national initiative from the Center for Medicare & Medicaid Services (CMS) to reduce the rate of all bloodstream infections by 50% of the 2016 rate to insure better health for people in the United States living with ESRD.
Infections are the second leading cause of death in patients with end-stage renal disease (ESRD). The cause for a majority of these infection is catheter- related  blood stream infection. As a result, CMS has developed a three part project to ensure safety and a high level of quality care to all ESRD patients.
  1. Reduction of blood stream infections using Center for Disease Control (CDC) core interventions
  2. The reduction of long term catheter use
  3.  Encouraging participation in a healthcare information exchange platform
The Network will be working with 50% of facilities who had thee highest BSI rate reported to the National Health and Safety Network during the first and second quarters of 2017. 

A priority of the Network is to serve as a resource to both dialysis patients and professionals throughout project activities.  Open communication about existing processes, barriers, and successes is encouraged.  Network staff members are interested in supplementing resources for what is working in your facility, not adding additional burden. However, in order to assess barriers, and identify how the Network can effectively meet needs of the community, completion of the ACTION REQUIRED activities (to the left) is essential for success of the project.
NOTE: Documentation of BSIs in NHSN is vital, as it will be the source of measuring improvement at the facility-level.
CMS Inclusion Criteria
Your facility has been selected to participate in this QIA, based on the semi-annual pooled mean rates reported in NHSN for your facility during the baseline period (January through June 2017).
All facilities that have a 15% or greater long-term catheter use rate as of June 2017 will also be requires to participate in activities to reduce the use of LTCs.
All facilities in this project are being encouraged to enroll in a healthcare information exchange platform.
Project Goals
Participating facilities shall demonstrate a 20% or greater reduction in the semi-annual pooled mean rates reported in NHSN for your facility from baseline to re-measurement (January through June 2018).
All facilities in this QIA with a LTC rate greater then 15% is required to demonstrate a minimum of a 2% rate reduction.
Project Interventions

BSI Rate Reduction Activities 

* Implement CDC core interventions

*Perform root cause analysis on identified barriers

*Complete NHSN training

*Partner with the CDC Making Dialysis Safer Coalition

* Appoint a patient ambassador

*Training patient to preform hand hygiene audits 


LTC Rate Reduction activities

* Appoint a Vascular access coordinator

*Establish peer to peer mentoring

*Tracking patient with LTC

*Developing a relationship with Vascular Surgeons groups

We Want to Hear from YOU!
Please contact the Quality Improvement Department if you have questions, comments, or specific barriers that you would like to address.  Let us know if you have identified any best practices that you would like to share with the community.