National Healthcare Safety Network Data Quality QIA

Project Guidelines

IPRO ESRD Network 1 of New England will be implementing CMS designated activities with facilities chosen for this QIA to improve communication between the Dialysis facilities and hospitals. Communication is essential to capture and report blood cultures collected outside of the dialysis clinic, on the day of, and on the day after hospitalization (within one calendar day). In an attempt to capture this information a new question was added in January 2016 to the Dialysis section of the NHSN data collection system. The project will be conducted over the next four year period. It is the overall goal of the project to improve rates of BSI identified in the hospitals and reported by dialysis facilities in the NHSN.

AIM:  Minimum of 20 facilities and 5 hospitals; 3 cohorts spanning 3 years

Baseline: January - June 2016 and re-measure is January - June 2017

Goal and Timeline:  Improve communication of key information between hospitals and facilities, and improvement in BSI reported in hospital setting.

Tools and Resources

Facilities involved in the NHSN Data Quality QIA

Hospital BSI Reporting - Provided by the Centers for Disease Control and Prevention (CDC)

How to Improve PBC Surveillance in Your Facility - Created by NHSN to assist providers

Interventions - Provided by the network

NHSN Data Quality QIA Presentation - Presentation created by the Network as an overview of NHSN Data Quality QIA

PBC Collected in other Locations CDC Flyer - Provided by NHSN

Personal Health Record -  Created by the Network to assist patients to better manage their health and medications. Patients are to take this Personal Health Record with them to wherever they go, including ALL doctor visits and future hospitalizations.

Man sitting on Desk


Jaya Bhargava, Ph.D., CPHQ
Regional Operations Director