Organizational Lead Manual

AHRQ Safety Program for Long-Term Care: CAUTI

February 2014 Version 1

Organizational Lead Operation Manual


Organizational Lead Operation Manual 2

TABLE OF CONTENTS

INTRODUCTION ....................................................................................................................... 4

Program Description .................................................................................................................................. 4

Manual Purpose and Organization ............................................................................................................ 4

The Role of the Organizational Lead.......................................................................................................... 5

PHASE 1: Planning ................................................................................................................... 8

Key Activities .............................................................................................................................................. 8

Planning Phase Activities and Resources Matrix ....................................................................................... 9

Planning Phase Checklist ......................................................................................................................... 13

PHASE 2: Execution ................................................................................................................15

Key Activities ............................................................................................................................................ 15

Execution Phase Activities and Resources Matrix ................................................................................... 17

Execution Phase Checklist ....................................................................................................................... 19

PHASE 3: Sustainability ............................................................................................................21

Key Activities ............................................................................................................................................ 21

Sustainability Phase Activities and Resources Matrix ............................................................................. 23

Sustainability Phase Checklist .................................................................................................................. 24



Dear Organizational Lead,

Welcome to the AHRQ Safety Program for Long-Term Care: CAUTI!

The Health Research & Educational Trust (HRET) developed this short Organizational Lead Manual to

assist you in leading and managing this national resident safety program for long-term care facilities.

We look forward to your ongoing feedback on how we can make this Manual and the resources we have

assembled be as useful to you as possible. HRET staff will periodically ask for your feedback; however,

please do not hesitate to let us know at any time about what aspects of the Manual could be improved

to help you by contacting Anna Wojcik, HRET Research Specialist, at [email protected], or 312-422-2656.

HRET and our national partners— University of Michigan, Abt Associates, Association of Professionals in

Infection Control & Epidemiology (APIC), Baylor College of Medicine, Society of Hospital Medicine

(SHM), Qualidigm (Connecticut QIO)—look forward to working with you every step of the way to help

ensure a successful program in our journey to improve care and prevent resident harm.

Sincerely,

Barb Edson, RN, MBA, MHA

National Program Director, AHRQ Safety Program for Long-Term Care: CAUTI

Vice President for Clinical Quality

Health Research & Educational Trust

mailto:[email protected]



INTRODUCTION

Program Description

The Agency for Healthcare Research and Quality (AHRQ), as part of the U.S. Department of Health &

Human Services (HHS) National Action Plan to Prevent Healthcare Associated Infections, is funding a

three-year resident safety improvement collaborative entitled, AHRQ Safety Program for Long-Term

Care: CAUTI in which long-term care facilities (LTCFs), chiefly nursing homes, can participate in a 12-

month national implementation program to reduce catheter-associated urinary tract infections (CAUTIs)

and other health care-acquired infections (HAIs).

This national implementation program will include a change package that has a combination of clinical

and cultural interventions to reach our aim of improving care and preventing resident harm. The change

package will include the following components:

o Evidence-based CAUTI and HAI prevention practices

o Safety culture improvement practices

The expected outcomes include:

o Improved safety culture evidenced by enhanced teamwork and communication

o Reduction or maintenance of zero CAUTI rates

o Improved awareness and application of infection prevention and safety culture training that

impacts other HAIs

o Staff infection prevention training

Expert faculty will train staff of participating LTCFs on how to implement and effectively use HAI

elimination practices and safety culture tools. In addition, LTCF staff will receive ongoing coaching, data

collection and reporting and progress monitoring support from the National Program Team (NPT).

Participating LTCFs will be able to network on a regional and national level with other facilities enrolled

in the program for peer-to-peer learning through activities such as web conferences, virtual and in-

person meetings and coaching sessions. Further, facilities will also receive program management

support from you, their Organizational Lead (OL). All LTCFs enrolled in the program will participate for

approximately 12-months in a cohort; HRET will launch multiple groups or cohorts of lead organizations

and their participating LTCFs throughout its three-year contract period.

Manual Purpose and Organization

The purpose of this manual is to help you, the Organizational Lead (OL), successfully manage your

participating facilities in the AHRQ Safety Program for Long-Term Care Facilities: CAUTI. It is different

from the Facility Implementation Guide which explains the clinical and cultural interventions your

facilities will undertake to improve safety culture, enhance teamwork and eliminate CAUTIs in their

facility.

The OL Manual starts with a summary of Organizational Lead roles and expectations, followed by the

three phases of the project life cycle: Planning, Execution and Sustainability. Each phase discussed in



this manual includes a chart called the “Activities and Resource Matrix”, which describes each activity

you will need to perform as you implement this program within your organization. Materials that you

need in order to accomplish individual tasks are referenced in each activity, and they will be available on

the program website (www.ltcsafety.org) under the “Organization Leads” tab. Each section of this

manual also includes a checklist of activities and their expected completion dates. These checklists

contain ongoing, monthly activities, so you may find it helpful to print one for each month of the

Execution and Sustainability phase to keep track of your expected activities.

HRET will remind you of activities and due dates via electronic weekly updates. These updates will

highlight upcoming educational sessions, deliverable due dates, resource materials, successful facility

practices, as well as provide alerts of updates to the national program website. You should read these

updates thoroughly and are requested to pass them along, summarize or “cut and paste” sections from

these weekly updates into weekly communications with your facilities about upcoming project activities.

You may also choose to customize the information to fit your facilities’ specific needs.

The Role of the Organizational Lead

As the Organizational Lead (OL), you are crucial in supporting your participating facility teams’ success in

this initiative. Your first role will be in recruiting and engaging facilities to participate in this national

collaborative. HRET has available materials for you to customize and share with interested facilities,

including those for print and presentations developed for scheduled informational webinars. After

recruiting facilities, you will encourage and monitor your teams’ progress through each phase of the

project life cycle. While expert national faculty will direct you and your participating facilities through

the cultural and clinical interventions, members of the NPT will also work closely with you on the

operational aspects of your work addressed in this manual. As an OL, HRET expects you to:

o Provide feedback to HRET on program materials to ensure relevance to the LTC setting.

o Recruit 15 or more LTC facilities into the program.

o Travel to and attend one-day OL training in Chicago on March 2-3, 2014.

o Complete a Project Charter which will be discussed at the OL training.

o Have a general understanding of both the clinical and cultural interventions.

o Read HRET Weekly Updates which are the primary way HRET and other members of the NPT

communicate important information to you.

o Send weekly updates to your facilities, including information from the HRET Weekly Updates,

project calls and other sources you find useful.

http://www.ltcsafety.org/



o Communicate regularly (at least weekly) with your facilities. You, and not HRET, are the

primary communicator with your Facility Team Leads. Create a group e-mail of all your Facility

Team Leads and send them relevant material from the HRET Weekly Updates.

o Attend onboarding and training webinars or calls (approximately twice a month for 3 months)

and monthly content calls (remaining 10 months). Each of these content calls will address a

topic in more depth than the onboarding calls.

o Remind your facilities to fill out HRET evaluations following all education sessions

(onboarding, training modules, and monthly content calls) and review evaluation results. This

feedback helps you understand how your teams are doing and what additional support may be

needed. You are responsible for monitoring your facilities’ evaluation completion throughout

the program.

o Facilitate monthly Coaching Calls. As an OL you are required to lead the calls with a subject

matter expert and assigned HRET staff member. These informal calls are important

opportunities to clarify any questions that may arise from the national content calls, review

monthly data and progress, address implementation challenges and discuss critical success

factors.

o Schedule time for and communicate with facility leads after you review each month’s facility

data submission. HRET provides data reports for OLs to use in monitoring the results and

progress of each of their participating facilities. You will need to coach and support successful

data submission into the Comprehensive Data System (CDS) or facilitate your leads talking with

CDS Data Support Staff.

o Answer and troubleshoot any miscellaneous facility team/lead inquiries.

o With your assigned HRET meeting planner, refine the agenda, attend, host and lead three

Learning Session (kickoff, midcourse and final) in-person meetings (preferred) or webinars.

Webinars should still achieve in-person meeting objectives and it is highly encouraged that

interactive tools be used to facilitate team conversations. This includes e-mail correspondence

and calls with your HRET meeting/webinar planner. Your HRET meeting planner will provide

each in-person or webinar meeting draft agenda and all program materials for you to customize.

The HRET meeting planner will also arrange for presentations from faculty, either on-site and/or

live streaming.

o Engage in peer networking and learning. Participate in monthly OL calls with the NPT and other

OLs to share challenges and successes. Submit monthly status reports to the NPT; HRET will send

you reminders with a link to the report form.

o Perform other unanticipated program activities.



The total annual estimated time commitment for the OL is approximately 500 hours over the 15-month

period, or approximately the equivalent of a 25% full time employee.

Manual Updates

This is the first version of this manual. HRET updates this document as needed to reflect improvements

and tools that you or your facility teams may develop to enhance program implementation. Throughout

your cohort participation, any subsequent versions of this manual that are created will be dated,

announced and distributed to you via e-mail. We are also open to constructive feedback; if you have

suggestions on how to enhance or modify this Organizational Lead Manual, please do not hesitate to

contact Anna Wojcik, HRET Research Specialist, at [email protected], or 312-422-2656.

File Sharing

The National Project Team encourages you to share tools, strategies and resources nationally by posting

items in a centralized location. Email templates and tools to Justin Snow, HRET Research Specialist, at

[email protected], and they will be reviewed and posted on the national project website at

www.ltcsafety.org. This website will be password protected and accessible only to project teams. You

will be receiving the username and password from HRET.






PHASE 1: PLANNING

Timeframe: Months 1-3

Key Activities

Become familiar with project goals, structure, and expectations:

o Organizational Lead In-Person Training Meeting in Chicago

o Organizational Lead Manual (THIS MANUAL)

o Facility Implementation Guide

o National Project Website (www.ltcsafety.org)

Submit your Organization Commitment Letter

Complete a Project Charter and send to Ashley Hofmann at [email protected]

Recruit LTC facilities and obtain a Facility Administrator Commitment Letter, Data Use

Explanation (DUE) form and a Team Roster form from each facility. Return your complete Team

Roster to Ashley Hofmann at [email protected]

Ensure facilities complete a Facility Demographics assessment, baseline NHSOPS and Skills Test

Plan and host Learning Session #1 (Kickoff Meeting)

Complete a Facility Action Plan with each recruited facility

Communicate with facilities about the upcoming required educational events schedule,

including Learning Session #1, the Onboarding Webinars and Training Modules

Remind your facilities to fill out HRET evaluations following all educational sessions

The Planning phase happens over the course of three months at the start of the 15-month project. This

is the initial stage of the project, in which you learn about the program, commit to its goals and

participation requirements, develop your organization project charter and recruit your LTCFs. During this

phase, you will also lay the foundation for data collection and submission. You will receive information

on how teams can sign up and register for data submission online. One of the first important activities in

the planning phase is the in-person Learning Session #1 Kickoff Meeting and the required Onboarding

Webinars. It is essential for you, the OL, and as many of your facility team members as possible to

attend these educational sessions in the order they are presented. They will prepare you and your





teams in implementing CAUTI prevention and resident safety techniques and will present methods to

collect, submit and track data to assess progress.

Planning Phase Activities and Resources Matrix

Activity/Resource Description Used By, Attended By or

Completed By

1.1 National Program Website

The national program website includes background information, content resources, and all the tools needed to successfully implement the program. The website will be password protected. You will receive the username and password from HRET.

Used by: Organizational Leads and facility teams AHRQ Safety Program for Long-Term Care: CAUTI Website www.ltcsafety.org

1.2 Organizational Lead Info Call “Meet and Greet”

This one-hour webinar will familiarize you with the goals, structure and requirements of the project.

Attended By: Organizational Leads on February 6, 2014

1.3 Organizational Lead In-Person Training Meeting

This in-person training will provide an in-depth orientation into the goals, structure and your role in managing your facilities for meeting the requirements of the project. You will also have an opportunity to meet and network with other organizations in your cohort.

Attended By: Organizational Leads on March 3, 2014

1.4 HRET Subcontract This form indicates your organization’s commitment to the project and includes the requirements that the organization must meet to join this initiative and receive the funding available.

Completed by: Your Organization’s President/CEO You should email the subcontract to Jeanette Lyons at [email protected]

1.5 One-page Program Fact Sheet

This one-page fact sheet is to recruit facilities to the project. You can customize this flyer with your own organization name and logo where indicated, and use the flyer to market to facilities in your organization. This flyer can be found on pages 4-5 of your Enrollment Packet.

Used by: Organizational Leads to recruit and inform facilities about the program.

1.6 Facility Administrator Commitment Letter

The Commitment Letter defines what is expected of the participating LTC facility, and holds each facility accountable for the project goals and requirements throughout the length of the program. This form is found on pages 8-9 of your Enrollment Packet.

Completed by: Facility Administrator 1. You should fill in the facility contact information where indicated in yellow 2. Email the form to the recruited Facility Administrator for





completion 3. Instruct the facility to complete the form using their letterhead and return to you. 4. Email all completed forms to Ashley Hofmann at [email protected].

1.7 Data Use Explanation (DUE)

The facility CEO should sign a DUE form to signify his or her understanding of how process and outcome data will be used and protected throughout the project. You should include a blank DUE with each Facility Administrator Commitment Letter. This form is found on pages 10-13 of your Enrollment Packet.

Completed by: Facility Administrator You should email the signed DUE form to Ashley Hofmann at [email protected].

1.8 Facility Team Leader Tasks and Commitment Form

This form provides the Facility Team Leader month by month expectations, including his or her annual time commitment. This form is found on pages 6-7 of your Enrollment Packet.

Used by: Facility Team Leader This form does not need to be completed or returned by the facility team leader.

1.9 Facility Team Roster

This form lists the core members of each facility team working on this project. It asks for contact information on each member of the team and will need to be updated if there are staffing changes. This information is important for tracking team members, particularly the facility project team leader. Maintaining contact with the Facility Lead and Team may require multiple contact options, email, work phone number or work fax number. Ensure that the Team Roster is updated as your teams change and current team members leave or new members are added. This form is found on pages 14-15 of your Enrollment Packet.

Used by: Organizational Lead 1. Add your contact information where highlighted and email this form to the recruited Facility Team Leader for completion 2. Retain a copy for yourself and email a copy to Ashley Hofmann at [email protected].

1.10 Organization Project Charter

The Organization Project Charter helps construct the overall vision of the program, outlines initiative details unique to your organization and ensures alignment with the national project. It will aid you in identifying the improvement target and its importance,

Completed by: Organizational Leads Please submit your completed Project Charters by April 30,






scope, measures, schedule and the resources needed to successfully implement the project. At the initial OL training meeting, you will complete a draft Organization Project Charter to distribute and modify with your partnering facilities.

2014 to Ashley Hofmann at [email protected].

1.11 Facility Implementation Guide

This guide will help your facility teams implement the project in their facilities. This guide addresses both cultural and clinical intervention steps to be completed to optimize successful implementation of the program.

Used by: Organizational Lead and Facility Teams

1.12 Learning Session #1 “Kickoff Meeting”

Learning Session #1 is the first of three face-to-face (preferred) or virtual meetings you will plan and facilitate. During this Kickoff Meeting, HRET and other members of the National Project Team (NPT) will provide an introduction to the program and national faculty will provide didactic sessions on clinical and cultural program interventions. You should identify a date and venue within the recommended window that works for your facility teams. The Face to Face Meeting Logistics Form can be found on pages 16-17 of your Enrollment Packet. You can then work with your assigned HRET meeting planner to finalize the agenda and materials.

Facilitated and led by Organizational Lead Attended by: Facility Teams You should notify HRET of the confirmed date and venue for your Learning Session #1 and return the Face to Face Meeting Logistics Form by February 28, 2014 to Ashley Hofmann at [email protected].

1.13 Facility Action Plan

This is a formal action plan created by each participating facility to determine their goals, objectives and the scope of their work. During Learning Session #1, you will facilitate a session in which all of your facilities draft their action plans. They will then take the action plans back to their teams for buy-in and finalization. All facilities should submit their final action plans to you within two weeks of Learning Session #1. You will then review the plans and follow-up with Facility Team Leads to ensure that adequate planning is performed.

Completed by: Facility Teams

1.14 Onboarding Webinars

There will be five 45-minute onboarding webinars, which will prepare you and your teams in implementing cultural and clinical interventions and will present methods to collect, submit and track data to assess progress. You and your facility teams are required to attend each onboarding webinar.

Attended by: Organizational Lead and Facility Teams





As the OL, you are responsible for reminding your teams prior to each educational event and encouraging them to attend (e.g., email, phone calls, text message reminders). You should also encourage your facilities to fill out evaluations following each of the webinars.

1.15 Baseline NHSOPS Assessment

Facility teams will take the NHSOPS survey twice throughout the project, once at the beginning and once at the end of the project intervention. HRET Data Support will send the culture assessment link to each of your Facility Leads for them to distribute or administer to facility staff. You should then review your facilities’ baseline results and identify opportunities for organizational improvement.

Completed by: Facility Lead and Facility Team Members Used by: Organizational Lead

1.16 Skills Test This quarterly assessment will be administered by HRET (five times in total) and will be used to monitor the effectiveness of the educational sessions being provided throughout the program.


1.17 Data Collection Guide

This quick guide provides step-by-step instructions on how to enter the process and outcome data, and on how to run and interpret data reports so that you can monitor teams’ progress with data submission and performance improvement.

Used by: Organizational Lead and Facility Teams You will receive this Guide in April 2014 to share with your facilities.

1.18 Facility Demographics Assessment

This one-time assessment will be administered by HRET through a web-based survey to determine your facilities’ demographics, which will be used in the data collection process.


1.19 Data Collection Schedule

This is a generic data collection schedule to provide a calendar-view of process and outcome data collection. You should familiarize yourself with the cohort-specific data collection schedule for your facility teams. Use the cohort-specific schedule as a reference in e-mails, on coaching calls and in follow-up discussions with your teams.

Used by: Organizational Lead and Facility Teams



Planning Phase Checklist

Organizational Lead Task Expected

Completion Date

Actual Completion

Date

1 Attend the Organizational Lead “Meet and Greet” webinar. February 6

2 Advertise the program with the one-page Program Fact Sheet and provide call-in information for the Facility Informational Webinar.

February 21

3 Along with interested facilities, attend the Facility Informational Webinar.

February 21

4 Have your organization CEO/leadership sign the HRET subcontract and email it to Jeanette Lyons at [email protected].

February 28

5 Attend Organizational Lead Training In-Person Meeting in Chicago, IL.

March 2-3

6 Become familiar with Organizational Lead and Facility Implementation manuals and the ltcsafety.org website.

March 10

7

Set up an email distribution group list of all your facility team leaders and start sending weekly email project updates, deadlines and educational program reminders. The HRET weekly updates are useful for “cutting and pasting” material into facility specific weekly updates.

March 10

8

Recruit 15 LTC facilities into the program. Ensure your facilities have registered using the online registration form and web link provided by HRET. Contact Neel Pathak at [email protected] for registration questions.

March 10

9 Obtain a signed Facility Administrator Commitment Form from the administrator or senior leader of each recruited LTC facility. Email a copy to Ashley Hofmann at [email protected].

March 10

10 Provide each Facility Administrator with a Data Use Explanation Form (DUE) to sign and return. Email a copy to Ashley Hofmann at [email protected].

March 10

11 Two weeks before Learning Session #1, hold a brief call with all your facilities so that teams can meet each other and you can remind teams about Learning Session #1.

March 10-21

12 Send each of your facilities a Team Roster to complete and send back to you. Email a copy to Ashley Hofmann at [email protected].

March 19

13 Host Learning Session #1. March 24-April 4

14 Ensure Facility Teams complete Facility Demographics assessment.

April 1

15 Remind facility team members to attend Onboarding Webinar #1, Building a Team.

April 3








16 Attend Onboarding Webinar #1, Building a Team, with your facility teams. Remind facilities to complete evaluations.

April 10

17 Obtain final Facility Action Plans within two weeks of Learning Session #1. Review the plans and follow-up with Facility Leads to ensure that adequate planning is performed.

April 7 - 18

18 Attend Onboarding Webinar #2, Understanding NHSN-LTC CAUTI Definitions, with your facility teams. Remind facilities to complete evaluations.

April 17

19 Attend Onboarding Webinar #3, Data Collection Training, with your facility teams. Remind facilities to complete evaluations.

April 24

20 Obtain final Facility Action Plans within two weeks of Learning Session #1. Review the plans and follow-up with Facility Leads to ensure that adequate planning is performed.

April 7 - 18

21 Complete the Project Charter and submit to Ashley Hofmann at HRET [email protected].

April 30

22 Ensure Facility Teams complete Skills Test. April 30

23

After teams have received their Comprehensive Data System (CDS) usernames and passwords from HRET, confirm that all of your facility teams have begun submitting their weekly data into CDS after training.

May 1

24 Ensure all facility staff members complete NHSOPS Baseline. April 2014




PHASE 2: EXECUTION


Key Activities

Participate with your facilities on the remainder of the Onboarding Webinars

Participate with your facilities on the Training Modules

Lead and facilitate monthly coaching calls and encourage your facilities to attend these calls

(Example agendas and email templates will be provided)

Participate in monthly Organizational Lead Calls

Continue to reinforce Facility Lead and Team expectations

Ensure your facilities are submitting program data (CAUTI outcome and process data) to HRET

as required and outlined in the data schedule and monitor your facilities’ progress

Coach Facility Leads to increase data submission for those facilities with less than 70%

submission

Review your facilities’ baseline safety culture (NHSOPS) results and discuss results with teams.

Identify and remove barriers, seeking NPT support as needed.

Follow up with identified facilities that need extra support

Participate with your teams on monthly Content Calls on clinical and cultural interventions

Read HRET Weekly Project Updates

Send weekly updates to your facility teams through group emails (“cut and paste” from HRET’s

weekly updates)

Submit short monthly status report to NPT (online fill-in-the-blanks template)

Coordinate Learning Session #2 (Midcourse Meeting)

Identify exemplary facilities and share their success stories with HRET for potential Content

Calls and other educational events

The project’s execution phase focuses on facilities’ implementation of lessons learned on

webinars/teleconferences and submitting CAUTI process and outcome data. In addition, you and your

facilities will review the baseline safety culture assessment results (NHSOPS) obtained in the planning

phase and discuss opportunities for improvement with Facility Team Leads.



Coaching As the OL, you have the important task of coaching your teams to improve resident safety culture, and

reduce or maintain near-zero CAUTI rates. This coaching is provided during monthly Coaching Calls, led

by you. A pre-coaching call with HRET and assigned NPT faculty will prepare you for these coaching calls

before they begin. An HRET advisor and a member of the faculty will also work closely with you in

helping to identify relevant topics, address data submissions and trends and troubleshoot and answer

questions from the teams on these calls. The NPT will provide you with agenda templates and coaching

training. As in the planning phase, you will be an important coach to your Facility Leads. It is important

to reinforce your expectations of each Facility Team Leader, who in turn is expected to reinforce

program expectations with their facility team members.

Monitoring Progress The importance of monitoring process, outcome and quality improvement activity data cannot be

overstated—measuring program results is a core continuous quality improvement activity. All data

collected for this project will be kept confidential and no resident-level or protected health information

will be collected. Facility-identified data will only be available to the facilities, to their specific OL, and to

the NPT, all of whom have signed confidentiality agreements. An HRET advisor will be assigned to you

and your teams to support the data management work that will begin in this phase. You will learn how

to use and submit data through the project database, the Comprehensive Data System (CDS) and you

are responsible for ensuring that your facilities are submitting the appropriate data according to the

established schedule. You will need to follow up with Facility Team Leads in facilities that are either

behind in data submission or whose data results indicate the need for additional support. Prompt

follow-up with Facility Team Leads is imperative whenever facilities have missing data or their data

indicates challenges. HRET staff and expert faculty are available to support you in this effort. If you feel

that a facility is facing particularly difficult challenges or is in jeopardy of dropping out from the program,

please contact Tina Adams, Clinical Content Development Lead at HRET, at [email protected], who will

work with you on brainstorming and implementing solutions. If needed, she will also walk you and the

facility through a facility disenrollment process.




Execution Phase Activities and Resources Matrix

Activity/Resource Description Used By, Attended By, or Completed By

2.1 Onboarding Webinars (weekly or biweekly during the first two months)

There will be five 45-minute onboarding webinars, which will prepare you and your teams in implementing cultural and clinical interventions and will present methods to collect, submit and track data to assess progress. You and your facility teams are required to attend each onboarding webinar. Topics include: #1. Building a Team

#2.Understanding NHSN-LTC CAUTI Definitions

#3. Data Collection Training

#4. Infection Prevention Skills Training

#5. Enhancing Your Resident Safety Culture

You are responsible for reminding your teams prior to each educational event and encouraging them to attend (e.g., email, phone calls, text message reminders). You should also encourage your facilities to fill out evaluations following each of the webinars.


2.2 Training Modules There will be four training and skills development webinars around infection prevention topics. Topics include: #1. Hand Hygiene and Standard CAUTI Prevention #2. Environment and Equipment #3. Isolation Precautions #4. Antibiotic Stewardship You are responsible for reminding your teams prior to each educational event and encouraging them to attend (e.g., email, phone calls, text message reminders). You should also encourage your facilities to fill out evaluations following each of the webinars.


2.3 National Content Calls or Webinars (monthly after the end of onboarding calls or training modules)

The NPT hosts and presents monthly 45-minute national content conference calls or webinars over the course of the project on topics related to CAUTI prevention, the safety culture model and tools and highlighting the experiences of facility teams. HRET will advise you of the schedule and send you slide decks

Attended by: Organizational Leads and Facility Teams



in advance of the call. You should attend and encourage your teams to join these calls. You should also encourage your facilities to fill out evaluations following all the content calls.

2.4 Coaching Pre-Call This call with HRET and assigned faculty will prepare for your coaching call series that begins in June 2014.

Attended by: Organizational Leads

2.5 Coaching Calls These 30-45-minute coaching calls will occur monthly starting soon after the Onboarding Webinars at a consistent date and time. These informal, lead organization specific calls will be facilitated by you, and will provide you and your teams the important opportunity to review their performance data, discuss barriers and share successes, ask questions, and mentor one another. An assigned faculty and HRET advisor will participate on these calls and support you in their development.

Facilitated and lead by: Organizational Leads. Attended by: Facility Teams

2.6 Coaching Call Faculty Request Form

This form is used to request additional faculty support for an upcoming coaching call should there be a planned topic that your assigned faculty does not have knowledge of. As soon as an appropriate faculty member has been identified, he/she will contact you.

Completed by: Organizational Leads Send your completed request forms at least 3 weeks prior to the date of the call to Tina Adams at [email protected].

2.7 Organizational Lead Calls

These informal, interactive, monthly Organizational Lead Calls will be led by HRET and are the venue for all OLs to share experiences, ask questions of the NPT, and learn from other OLs and their best practices.

Attended by: Organizational Leads

2.8 Weekly updates to facilities

Regular communication with your facilities is very important. You should adapt or “cut and paste” sections of the HRET weekly update email into your own weekly update emails to your facilities.

Completed by: Organizational Leads




2.9 Learning Session #2 (Midcourse Meeting)

The Learning Sessions are opportunities for facilities’ staff to come together as a group in person to share their challenges and best practices. A faculty member from the NPT will attend onsite, or virtually. Your HRET meeting coordinator will work closely with you on meeting planning; HRET assistance will include supplying the meeting agenda template, scheduling your faculty, and providing slide decks with any handouts that will be used in the meeting. You should identify a date and venue within the recommended window that works for your facility teams. The Face to Face Meeting Logistics Form can be found on pages 16-17 of your Enrollment Packet. You can then work with your assigned HRET meeting planner to finalize the agenda and materials.

Facilitated and lead by Organizational Lead Attended by: Facility Teams

Execution Phase Checklist


Completion Date Actual Completion

Date

1

Remind units a week in advance of any type of project call and deadlines, and direct them to www.ltcsafety.org for a calendar of events and archived recordings.

Ongoing

2

Participate with teams on remaining onboarding webinars. Remind facilities to complete evaluations after each webinar. #4: Infection Prevention Skills Training #5: Enhancing Your Resident Safety Culture

May 2014

3

Participate with teams on Training Module webinars. Remind facilities to complete evaluations after each webinar. #1. Hand Hygiene and Standard CAUTI Prevention #2. Environment and Equipment #3. Isolation Precautions #4. Antibiotic Stewardship

May-July 2014

4 Participate in coaching "pre-call" with HRET and assigned faculty to prepare for your coaching call series that begins in June 2014.

May 2014




5

Prepare agenda for coaching call and send it out to your unit teams, assigned faculty and HRET advisor. HRET will work with you to schedule a consistent time each month that is convenient for you, your facilities, assigned faculty and HRET advisor.

Two weeks prior to each scheduled coaching call

6

Lead and facilitate monthly coaching calls and encourage your facilities to attend these calls. Following each coaching call, e-mail a summary of call highlights and recognize teams that shared information.

Monthly, starting June 2014

7 Review facility data, progress and action plans to address barriers and concerns of facilities.

Monthly

8 Follow up with facilities experiencing no improvement, document conversations and corrective action plans.

Monthly

9 Attend monthly Organizational Lead Calls. Monthly, starting June 2014

10 Submit online monthly Organizational Lead Status Report.

Monthly

11 Ensure Facility Teams complete Skills Test. July 2014

12

Meet by phone with an HRET meeting coordinator to plan Learning Session #2. Secure venue for Learning Session #2, and confirm all meeting and video logistics.

August-September

(2 months prior to

meeting)

13 Hold Learning Session #2. October-November 2014

14 Ensure Facility Teams complete Skills Test October 2014

15

Submit to your meeting planner the Learning Session #2 evaluation results and a brief one page description of the number of attendees, lessons learned, and ways to improve further programs.

October-November

16 Ensure Facility Teams complete Skills Test January 2015

17 Plan facility site visits as needed and determined by you: identify potential facilities and participate in coordinating the visits.

Ongoing



PHASE 3: SUSTAINABILITY


Key Activities

Continue to participate with your facilities on monthly National Content Calls

Ensure your facilities are submitting evaluations following every Content Call, and all other educational sessions

Continue to facilitate monthly Coaching Calls and monitor and discuss facility data

Maintain communication with your assigned faculty member(s) to plan input needed during

coaching calls, and ask them to speak about sustainability

Reach out to the NPT for help answering facility teams’ questions

Follow up with individual facilities that need extra support in collecting or submitting data or in

lowering their CAUTI rates; have high-performing teams share success strategies on your

monthly coaching calls.

Read HRET Weekly Project Updates

Participate in monthly Organizational Lead Calls

Submit monthly Organizational Lead Status Reports to HRET; capture success stories, strategies

and barriers

Educate yourself and facility teams on project sustainability tools and strategies

Develop your sustainability plan: how your organization will support CAUTI prevention and

resident safety after participation in the national collaborative ends

Encourage your facilities to develop their own sustainability plans

Ensure facilities complete a final NHSOPS assessment; web link will be provided by HRET

Host and facilitate Learning Session #3

Sustainability

The AHRQ Safety Program for Long Term Care: CAUTI has been designed to help ensure sustainability.

Beyond the educational curriculum, however, several critical success factors are required for sustaining

the interventions learned and continuing gains in process and outcome improvement:



1. Identify and develop program champions. These staff and administrators are motivated and enthusiastic about the practices they promote and will be key in facilitating prevention activities in their facilities.

2. Identify and develop the implementation team. The team should include key staff and administrators, but should work to engage residents and family as well.

3. Empower staff to speak up when a potential break in resident safety protocol occurs. Staff should be commended, and not punished, for speaking up for resident safety.

4. Establish processes for data collection and reporting to collect process and outcome data, and use those data to continuously improve performance by providing feedback to the facility staff using this data.

5. Manage skepticism and resistance through the active involvement of administrative and clinical champions. Coach Facility Team Leads to motivate team members to try the program interventions and provide dedicated time and adequate resources.

6. Engage staff with stories, which are a powerful way to engage staff in ways that numbers cannot. Encourage your Facility Team Leads to discuss actual resident stories to drive home important lessons.

7. Engage staff with data, which are a clear way to educate staff about the scale and impact of resident safety and infection prevention issues in ways that stories cannot. Encourage your Facility Team Leads to discuss data reports to drive home important lessons.

8. Recognize and celebrate successes, small and large, and both early-on and long-term. Communicating success will help staff gain the courage to speak up and reinforce for the entire team the importance of program interventions. Share stories of ‘good catches’ when resident harm has been prevented to inspire and motivate staff, and reward those that speak up to increase resident safety.

The goals of the Sustainability period are twofold: 1) to sustain improvement in CAUTI prevention and

resident safety and 2) to determine a process management plan for your organization and for your

facilities. This plan should include three elements:

a data collection and review process,

acceptable data limits, and

a plan for facility teams to return to the Execution phase when data indicates it is necessary.

Although the Sustainability phase occurs in the final three to four months of the national project, you

should begin planning for sustainability right from the beginning of the project.

During the Sustainability phase, encourage your teams to continue the improvement work they started

while participating in the national project. You and your facility teams are expected to participate in all

educational programming, including national Content Calls and webinars. You are responsible for

ensuring that your facility teams complete evaluations following each of these educational sessions. You

should communicate this expectation to facility teams through email, coaching call content, and in one-

on-one conversations.

As in the Execution project phase, you are responsible for monitoring your teams’ monthly outcome and

process data submission, and CAUTI rates. This tracking will allow you to continue to coach struggling

teams through individual phone follow-up, or site visits and, if appropriate, to connect them with a high-



performing team leader for peer-to-peer learning. You should arrange to have high-performing teams

share their strategies on monthly coaching calls. Peer-to-peer learning is very powerful; having teams

share challenges and successes on the coaching calls is important throughout the project, and continues

to be so during this phase of transition to sustainability. Common themes from your facilities’ final

NHSOPS survey will be useful discussion topics for your remaining coaching calls.

Sustainability Phase Activities and Resources Matrix

Activity/Resource Description Used By, Attended By, or

Completed By

3.1 Final NHSOPS Assessment

The final safety culture assessment will be administered in April 2015. HRET Data Support will send the culture assessment web link to each of your Facility Leads for them to distribute or administer to facility staff. Review your facilities’ final safety culture assessment results and encourage your facilities to identify what is working well and opportunities for improvement.

Completed by: Facility Lead Used by: Organizational Lead

3.2 Learning Session #3 (Final Meeting)

The third and final in-person meeting of the project occurs during the final months of the collaborative. Learning Session #3 also allows teams to celebrate progress made during the program and to formulate and communicate plans for sustainability and spread. A representative from the NPT will attend onsite. Your HRET meeting coordinator will work closely with you on meeting planning. HRET assistance will include supplying the meeting agenda template, scheduling your faculty, and providing slide decks with any handouts that will be used in the meeting. You should identify a date and venue within the recommended window that works for your facility teams. The Face to Face Meeting Logistics Form can be found on pages 16-17 of your Enrollment Packet. You can then work with your assigned HRET meeting planner to finalize the agenda and materials.

Facilitated and Lead by: Organizational Lead Attended by: Facility Teams

Sustainability Phase Checklist


Completion Date Actual

Completion Date

1

Educate yourself and your facilities on sustainability tools and strategies.

Ongoing

2

Continue to monitor facility process and outcome data.

Monthly

3

Follow up with facilities that have high CAUTI rates and with facilities that need extra support with data submission.

Monthly

4

Reach out to NPT and Faculty for help responding to questions/needs of facility teams.

Monthly

5

Participate with your Facility Teams on monthly Content Calls. Remind facilities to complete evaluations after each call.

Monthly

6

Lead and facilitate monthly coaching calls and encourage your facilities to attend these calls. Following each coaching call, e-mail a summary of call highlights and recognize teams that shared information.

Monthly

7 Participate in monthly Organizational Lead Calls. Monthly

8

Continue to submit monthly Organizational Lead Reports to the NPT and capture any success stories and strategies.

Monthly

9

Meet by phone with an HRET meeting coordinator to plan Learning Session #3. Secure venue for Learning Session #3, and confirm all meeting and video logistics.

February 2015

10 Finalize a sustainability plan; How will your organization support CAUTI prevention after the national collaborative ends?

March 2015

11 Ensure all facility staff members complete final NHSOPS assessment.

April 2015

12 Ensure Facility Teams complete final Skills Test. April 2015

13 Host and facilitate Learning Session #3. April 2015

14

Submit to your meeting planner the evaluation results and a brief one page description of the number of attendees, lessons learned, and ways to improve further programs.

April-May 2015

15 Review NHSOPS survey results and encourage your teams to continue to review the results and identify opportunities for improvement.

May 2015

Documents

Organizational Lead Manual