Using the Opportunity Estimator (Transcript)

July 20, 2010

Operator: Good day, ladies and gentlemen, and welcome to the CUSP supplemental conference call. At this time, our participants are on a listen-only mode. Later, we'll conduct a question-and-answer session and instructions will be given at that time. If you need operator assistance during the conference, you may do that by pressing star then zero on your touchtone telephone. As a reminder, this conference is being recorded. I would now like to introduce your host for today's conference, Mr. Jordan Duvall. Sir, you may begin.

Jordan Duvall: Thank you. Good afternoon, everybody. Today we're going to be speaking about how to use the opportunity estimator to integrate into your CUSP activities. We're also going to go over the senior and executive checklist to supplement your work in the On-the-CUSP Stop BSI program.

If you go to the first slide, you can get a quick idea of what we're going to be talking about today. Hope to spend about 10 to 12 minutes to speak, and then Dr. Christine Goeschel will discuss the senior and executive checklist, and then we can have some time for discussion and questions about what we went over today.

We're going to begin by briefly introducing the opportunity estimator. I'm not sure how many of you have had a chance to use it, but we're going to quickly take a look at it, put in some sample data, very briefly discuss how it was developed, and then where you can go to find it. Then we'll actually talk about how to use it to support CUSP activities, specifically how it integrates into CUSP Steps one, three, and five.

So, if we advance to slide number three, we're going to cover these three topics. What is it? How does it work? And where is it located? Pretty straightforward.

So, the opportunity estimator, if you advance to slide four, is a tool that requires using little time or special training, in terms of generally abstract metrics, which is the incident of CLABSI infection into tangible measurement. It can be used several different ways alongside key components for CUSP. This is an evidence-based tool that translates rate data into tangible outcomes based on a conceptual framework of translating research into practice. And the opportunity estimator can allow you to address three of four key concepts based on this framework, which are we are part of the four E's, which is to educate, engage, evaluate, and execute. The opportunity estimator facilitates the education, engagement, and evaluation portions.

On slide four, you can see the basics. This is a Web-based and delivered application. As you can see here, there are several key fields where you can input data and some are pre-populated. If you go from top to bottom, this is where you would enter in your central line data. And this can be for any period, so this can be for 1 month or 6 months or 12 months. You're entering your central line data. And then the next is the case fatality. So this, as I said, was evidence-based, so we went through the literature and found what the ranges were in the literature for these different metrics. One being case fatality, one being the cost per CLABSI, and one, the last, being the additional length of stay and the additional number of days patients stay in the ICU or on the floor that they're admitted to based on the infection. They're pre-set at the median values, and if you know your own information, you can change them. If you know your own case fatality rate within your own institution or if you know how much each CLABSI costs, you can enter in that data. After entering the central line data, the typical use would be to go and enter your number of infections. As you do this, the values will change, and you will be able to see on the lower left the current burden based on your information, and then on the right, in blue, what the potential savings would be for each, for a percent decrease in the infection rate. So, we pre-populated the 10 percent, 25 percent, 50 percent, and so on.

If you advance down to the next slide, slide five, this is just the conceptual framework for how the opportunity estimator was created. It's a little detailed. We won't go into it, but it can just give you an idea that you're going to take your information in terms of a rate. You're going to enter it into the opportunity estimator, and it's going to translate that rate data into these tangible metrics of cost and length of stay, and then it's going to show you what your current burden is and what the potential savings are for a decrease in your infection rate, and then how to use it. So, you can use it within a collaborative project like this or for different institutional quality assurance or performance improvement project, and then you can, within the framework of those types of projects, you can then use it to engage, educate, and evaluate.

And advance to slide six. So this is on the estimator itself. There is a tab that says "References," and if you go in there, you can see for each of the outcome measures that we have incorporated into the opportunity estimator, there is the reference and the link to either the document itself, the publication itself, or the Pub Med ID. For each of these listings, there is also an abstract as it's been referenced in Pub Med. This is important, as we'll talk about, when you educate your staff because you can simply either point them to this reference section to kind of get an idea of what the data show or actually to go and get the documents themselves. But we'll talk about that a little bit further as we go on.

So, if you go on to slide seven, this is an example of it in use. So, let's say I put in 904,019 central line days, and then I leave it at default setting because I don't know what the case fatality rate, the cost per CLABSI, or the additional length of stay are for my institution or my organization. I hit "estimate," and over on the left it'll show me that based on this current profile what the current burden is. There are 220 access deaths, 1,789 CLABSI infections, $94, almost $95, million, and an additional 14,312 additional days spent in the ICU. This is pretty compelling. I think if you go from an incidence rate of 1.95 CLABSI per 1,000 central line days, so that tells me something, but for this period, maybe I don't exactly know what that's telling me, but when I see it in terms of these more tangible outcomes, that dollars and days, it's quite compelling.

So, if we can go onto slide number eight, where is it? This link here, which is not a hyperlink -- it's just text, so don't try to go on and click it — will take you to a page on the safercare.net Web site, which has a link to the opportunity estimator and a little more detail about how it's used, how it's developed. Also, relevant for this talk on this page is the link to the senior executive checklist that Dr. Goeschel will be speaking about in a few minutes. So, I know that document did not get sent out. It's on the HRET project site, but if you wanted to quickly access it, you can just click on this link and there's a link, or you cannot click on this. You can type coe.saftercare.net into your Web browser and then download the checklist document for later in the talk.

So, advancing on to slide number nine. So, we know that CUSP work takes time, and we know that Stop BSI project requires a lot of effort and energy, ongoing. For those of you who have been doing it for a while now and also for our new members that may be listening or people that are new to the project, CUSP conceptually can be challenging to grasp as you start and really leverages on your experience doing the work in order to make this sensitive. And the other thing is that CUSP is ongoing. Organizing key CUSP activities around this tool may help you to implement CUSP in ways that are more efficient, clear on how the CUSP framework translates into actual work that we're doing every day in our institutions, and can help make implementing CUSP more consistent over time. The opportunity estimator can be used as a go-to or touchstone for repeating work throughout the effort and ongoing throughout the project.

So, CUSP activity number one: The science of safety. And I'm going to talk a little bit about how we can use the opportunity estimator alongside the science of safety to help educate staff. As staff learn how patient safety and errors are reliant on the systems we have in place, they can begin to understand that cultural components are instrumental in making change and making care safer. So, this step is crucial in laying the foundation for the work that we're doing, so facing changes in programs based on evidence provides a context that justifies asking team members to do the work. So, oftentimes the QA projects or performance improvement projects are put in place with little evidence to support them, or maybe the evidence exists but it's not transmitted down to key players or everybody on the team involved in the effort. And we'd rather, I think we've seen that it's sort of mechanistically decreed from mid or upper management or both and can be hard to gain buy-in from our team members who are doing the work day to day on the frontline. Providing the evidence behind the impact of infections, whether, like I said before, using references provided in the opportunity estimator on that reference tab -- we're simply explaining that there is evidence and it's scientific in nature -- exists in presenting the rate in tangible terms going from this incidence rate to deaths, dollars, and days helps to make the effect of CLABSIs real. It helps describe that the infections and their impact as components of a system can be changed because they are themselves components of the system. And I think that's something that we stress in the science of safety is that the system is designed to achieve the results that you see. And understanding that these outcome measures, that they themselves not only are an indicator of how the system is performing but as part of the system will allow people to feel as though they can change it, not simply because someone told them to change it without a reason. So, the system now, our health care system, our ICU, our floor -- wherever we may be implementing CUSP -- can now be defined in other terms. Lives can be lives that are saved. Dollars spent can be dollars that are saved. And beds filled can be beds available for others.

So, if we advance on to slide 10, in terms of how we would use it, so prior to watching the science of safety video, the opportunity estimator data for your organization or for your unit, wherever you're going to be doing this work, can be presented to staff to help focus the attention and allow the science of safety video to be viewed in terms of specific efforts. Like I said before, once they understand through the science of safety that they can make changes, there may be some more effort or energy or attention paid to watch. Presenting the data before, it kind of might help focus that attention to help absorb the lessons in the science of safety. You could also do it after watching the science of safety video. The opportunity estimator data can be presented to reinforce concepts that were in the video and allow the initiative that we're involved in, On the CUSP Stop BSI, to show that its really grounded in evidence. I think this is particularly relevant for new States that are coming on as CUSP teams are being assembled to help build audience engagement and pride by showing everybody that, "Look, we're doing some work that's not just changing a rate or some line on a graph but really making a difference." And as we saw before, the data can be easily and quickly generated for a single new team member or when an entire CUSP team is being put together.

We'll go on to slide 11. This is talking about engaging leadership. The CUSP step three is the senior executive partnership and similarly to educating staff, the estimator can provide a common starting point to engage senior executive leaders, presenting your current infection rate in these more tangible terms. So, on the slide here, kind of just put in some organizational charts, and these were the simpler ones that I could find, but often it's really hard to find a senior executive who is interested and willing to be participating in these big QI or QA projects, and they're really important. They're really important to bring on board to help bring about change. So, this identification of leadership is really crucial. It can be hard to identify a leader, let alone approach one once you found one and then ask for their involvement. So, what we've heard, and I think it's hard to walk into someone's office or to set or schedule an appointment, but it might be a lot easier to take the opportunity estimator and present the data in an email and say, "Hi. My name is Jordan. I'm working on this project. A part of it is to engage a senior leader, and I just wanted to tell you that our incidence rates for CLABSI infections for my unit for this period was 1.9 infections per 1,000 central lines." And then you might even say, "You might not know what that means, but what it means and what it meant in this case is that there were 220 lives lost and we wasted $95 million. Might you be interested?" And I guarantee you, well, I don't guarantee you, but I think you're presenting these measures, these very important measures, in that way may help you to get a response. I know that we're busy day to day doing our work, and management is busy, too, so it's just as important for them as it is for our staff on the frontline to know that there's evidence and that we can change the system. And that can be motivating for senior leaders as well. So, not only do we present this data to get the conversation started, but we should also be educating them in the science of safety, so it's important to be able to transmit some of that information also.

As we advance on to slide 12, often in health care, we hear about making the business case for change and especially with reform that's going on and our attention being focused on saving money and not being wasteful and becoming more efficient and effective and all these types of things, this is particularly relevant. And it's hard sometimes to focus on that, to say, "We need to make the business case," because it sounds a little cold that everything is a dollar, everything is viewed in terms of the cost or the benefit that we may see. And it's not to say that we shouldn't try to improve care -- because A, we can; and B, it's the right thing to do -- but rather see that it makes good business sense. Instead, I think we can really talk about it in terms of all-through. So, believing that leadership, our senior leaders and our executives, are also in health care for the same reasons that frontline providers are is important. I think they also want to make a difference. We know that. They want to help people, and they also want to save lives. It's important to acknowledge that no money can also mean no mission. So the business case for change is, in fact, important. So, by presenting the data from the opportunity estimator, two really important outcomes that have direct business implications are addressed: Dollars spent unnecessarily, in addition, the length of stay, which can affect all types of things from through-put, staff to patient ratio, resource allocation, management load, and things like that. So presenting these data not only can help to engage senior leaders but also can help to build awareness amongst management and gain support to the important and hard work that you and your teams are doing. They're strong motivation to help when you can prove with evidence that cost can be cut and efficiency improved, not to mention that lives are saved. So, we can use this early on in the project when you're building a CUSP team and you're identifying your senior leaders and executives. And this can also be especially important ongoing throughout the project of challenges to the work that we're doing in barriers to success horizons. And we know that from experience that this is hard work and requires time and energy and often we hear that people don't have enough time or they don't have enough resources, and senior executives and management are really going to be allied in helping protect time and dedicate more staff to the program implementation. They do often, however, need buy-in or approval from their higher up, and the same type of factor is relevant for them, can and will be relevant for those who may need to go and get you the support that you need. So, as I said before, sharing the opportunity estimator data with them as they come on board with the project is key and crucial but also to teach them how to take the infection rates themselves and be able to discuss what that means in more tangible terms. Also, I think, just as an afterthought, if there isn't money, the argument is “We don't have money to do this project” or “We don't have the resources to do it,” this really gets at the heart of what the opportunity estimator is about, which is the opportunity cost, or the trade-offs, or "Well, if we don't do it, it's costing us money. If we don't prevent or eliminate these infections, it turns not into a cost savings upfront, but a cost wasting continued and throughout." So, I think as we looked at that initial example of $95 million, how much would it cost to get another, to protect 20 percent of your time, or to bring another person on to help enter data or these types of things? This can be powerful stuff. The business case motivator is immediate, and it's ongoing, and infections equal lives, equal money, equal beds, and ultimately people's missed opportunities the longer that the work isn't being done.

As we advance on to slide 13, my computer's kind of slow, this is the last portion that we're going to talk about: How to leverage the opportunity estimator to help do your CUSP activity number five, which is tools to improve. And we'd like to talk about evaluating performance. This slide is pretty straightforward and basic and will become complicated when we get to the next slide. But as we go on, as we've been doing the work, we want to reinforce that work by using tools that will help us improve and maintain our progress as we go forward. So, tools like the learning from defects tool, the daily goals tool, and the morning briefing help to build team cohesion, improve communication, and help to focus our attention and purpose to the effort. The estimator can be incorporated as a regular part of your CUSP meeting and provide a vehicle for you to discuss past performance, looking at changes in your team's rate, and how that translates into the tangible measures that we talked about, as well as setting goals for the future based on evaluation of your current performance, and sort of using that Zen of the opportunity estimator that says, "Well, what if we decrease our rate by 10 percent? How many lives saved is that?" Or "What if we decrease it by 50 percent?" So, we can use this, looking at changes from month to month.

So, if we advance to slide 14, we can look at our past performance, and then we can look at our current performance and we can say, "Did the reduction in the rate, was there a decrease? Did the rate reduce or did the rate increase? And what does that mean? And how can we use that as we continue the work?" So, did it decrease? Immediately you can take that information and plug it into the estimator and determine how many lives saved, did that translate into dollars not spent or length of stay reduced? And much like the, I'm not sure if everyone's seen it, but if you haven't, we have a number of days without infections posted that we use throughout the unit to say, "We've been doing this well. We've gone this many days without infection." It really helps to rally the troops and build the team cohesion. So much like that, we can take this information and we can put that in there and we can say, maybe we can make a poster that says, "From January to June, we saved this many lives." Or "We avoided wasting this much money." But as you can see from that original information, it really can have an impact and also build awareness, too. But if you walked into a unit and said, "We saved 200 lives." I think the first thing I would ask is, "How?" And if I worked in a different unit or a different area of the hospital, I might say, "And how can I?" And I think that's another thing that we want to do is not only take the lessons we learned to help ourselves maintain our performance throughout the project, but share our wisdom with other groups to help spread the Stop BSI project from unit to unit, floor to floor, and ultimately hospital to hospital, and across the country. And if we did see an increase, we saw an increase, we went from 1.9 infections per 1,000 to 2.1. I don't know. That doesn't sound like too much to me, but when I put it into real terms, I think it might help to focus attention and sort of get people onboard saying, "Well, oh, my goodness, our rates increased. It had this result, and I don't want that to happen again. I don't want to miss the opportunity to save five lives." And it can really build support for participating in these other tools to improve types of activities like learning from these types. "Oh, well, our rate increased. The number of lives lost increased. What happened? Now, let's go and investigate it so it doesn't happen again."

If we advance to slide 15, we can look at our current performance. Like I said before, we can sort of shoot for goals in the future. Also, implemented during our regular CUSP team meetings, you can evaluate the current infection rate and what it means in terms of the tangible outcomes, and then say, "As of today or for this period, this is where we're at. This is our rate." And "What can we do for the future? How much better can we perform?" And simply setting a goal, saying, "I think we can save five lives by such and such time" or "I think we can save 10 lives in the next month" can have tremendous impact on performance, can really become a rallying point and at each meeting can feed back into the previous point made.

So, if you go to slide 16, this is where it gets a little confusing but more fun than anything. We can say, "Here we are. How did we do? Did we improve? Did we not improve? Let's set a goal for the future," and we incorporate this into our regular CUSP meeting and talk about it in terms of not just great or not just what the barrier was or why things may have not gone so smooth or why things went really smoothly, but to say, "Here we are, and this is how many lives we saved," or "What can we do to save more lives or to save more dollars? We have our senior leaders at the meeting and how could we use this $95 million or this $20 million or even something as basic as how might we better use our units to better take care of someone else who needs it rather than to have it in there or somebody who didn't need to be there." And we just incorporate this into our regular cycle and make it part of our common language for doing CUSP work On the CUSP Stop BSI initiative.

We go on to slide 17. So, the opportunity estimator in action. I hope nobody advanced through the slides. That's why I tried to hold off sending them until later last night so you wouldn't sneak peek the last page, but the opportunity estimator in action. So, the sample data that I used before on slide seven are the number of infections in central line data for the baseline period for all the data that we have currently for people participating in the collaborative. So, it's not everybody and it's not all the states or all the teams, but it's everyone that was in there that had base claim data of those that have submitted, and this was what was going on before we started our work: $95 million, 14,312 additional days, and 220 deaths. All these claims that could be prevented, that will be prevented, as we continue to do our work with your help. And if we can stick with it, if we can incorporate CUSP into our daily routines and we can keep a mind towards not only the infection rate and the infection but also what it means in real life, in real terms, maybe we can get to zero infections. And we won't have to worry about how many missed opportunities to save a life or to save some money or to free up a bed, but instead we can think about how to sustain and go forward and keep the infection rate at zero.

So, that's it. Hope that was informative. We, I think, are going to go now to Chris Goeschel to talk about the executive checklist and then we can have some time for discussion.

Christine Goeschel: Great. Thanks, Jordan, and hello, everyone. Jordan did a really thorough explanation of a powerful, powerful tool that sits on that Web site, the Stop BSI website, and every now and then someone uses it and goes, "Oh, my goodness, I forgot this was here" or "Did I look at this correctly? Because I'm stunned by what it means if we're going to reduce infections." So, when we talked about doing this call, we understood that we needed to do a step-by-step introduction, if you will, or reminder for how to use the tool. But realistically, when we started this work back in Michigan in 2003, the opportunity calculator, which is what it was called then, was nothing more than a basic Excel spreadsheet that allowed us to take what was in the literature at the time and begin to estimate, based on numbers needed to treat, what the potential impact of this work would be. We have come a long way since then, not just in our knowledge of the Comprehensive Unit-based Safety Program or the potential impact of this work, but also in the kinds of tools that we're giving to you to help advance your work at the local level. If someone asked me what the power is of that opportunity estimator, I would say, "It's the Big E." It is the tool that engages people, whether it's the senior leaders who want to see the dollars and cents, as Jordan said, or the potential throughput, dead capacity that they're going to gain if infections are reduced, or if it's clinicians at the bedside that want to see that the work that they're doing makes a difference, not only to patients and families, which are truly our North Star, but also in a way that gets us.  I can remember, again, back in the early days of the Michigan project, I think for the first time, quality and patient safety were on the radar screen of senior leaders. Think about that. It's not been that long ago, but pretty universally, teams were saying, "Yeah, our executives pay lip service to quality and safety, but we're really not on their radar screen." This tool allows you to add some dimensions to quality and safety work that puts you right square in the middle of the radar screen. But once you're there, and once your senior leaders are engaged with the numbers, whether it's that you go and, as Jordan suggested, point out that based on the infections that your infection preventionists have attributed to your intensive care unit or your floor, if you go in and say, "We have these many infections and it probably represents about this much money or this much opportunity to free up beds for other patients." Once they're engaged, senior executives are just like the rest of us, and they're just like many of you who are saying, "Okay, we're in. What do we do? What do we have to do to make this real?" And that's where the executive/senior leader checklist, again, is another tool. It's not perfect. It's not complete. It's not going to fit perfectly everywhere, but it allows you, when that executive says, "Okay, you've got my attention. We have infections. We have a problem. We're in this project. What do I have to do to support the work?" The checklist gives you a guideline for what you should be asking for. And I'm not going to go through the steps of the checklist. We've done that before on special calls. You've got the checklist, which is pretty self-explanatory on the Web site, and we could talk about this in more detail on any given coaching call because everybody that is part of the team can speak to this. But by and large, it gives senior executives tasks. Tasks attached to the Comprehensive Unit-based Safety Program, tasks attached to CLABSI. Use of the opportunity estimator allows you periodically to reinforce with that senior leader that the tasks they are supporting make a difference. For example, we asked executives to make sure that the science of safety is built into training for all new and current employees. If we say that it's important, then it needs to be embedded in the core work of the organization. We asked them to make certain that there's a senior leader or executive attached to each of your teams. We asked them, and we've talked about this on one of our recent coaching calls, we asked them to hold us accountable and to hold themselves accountable for what this work is, and so it goes. When we get to the tasks that we suggest executives need to embrace relative to CLABSI, we ask them to use their level of influence in the organization to make this real. So that means making certain that elimination of CLABSI is an organization-wide goal. Have it in your strategic plan. We ask them to support you and the infection preventionists and each unit in your hospital that is a part of this work to make sure that your efforts are coordinated. It doesn't help anyone to have 10 separate CLABSI teams trying to figure out how to report to the executive. Your work is local. It happens at the unit level, but in organizations that have multiple teams, the communication to senior leaders needs to be coordinated. We ask them to support some very specific tasks attached to supply procurement and availability, the things that we talk about all the time. And probably last but not least, and in my estimation, it's one of those things that helps close the loop on engagement, one of the second to the last slides that Jordan had is that we ask executives to be transparent about the infections in your organization. That is, to have everyone at the local unit level understand the number of infections and what that represents. Many of our hospitals are now posting pictures of patients who have had infections -- with, of course, the patient's permission -- to make the very real level of impact apparent. But by the same token, we want the numbers of infections, the opportunities lost on the impact throughout the organization. So, at Hopkins, we talk about the fact that senior leaders and everyone from the board to the department heads get a weekly report of harm, and we encourage in the checklist that senior leaders assure that there is a weekly report of infections and that it gets reported up on some regular frequency, not just to the teams that are doing the work but to other department heads, to senior administrative leaders, and ultimately to the board of trustees. I'm going to close my comments with an invitation that when we open the line, if Allison Hong or some of our colleagues from Connecticut are on the line, I'd ask them to talk a bit about their use of the opportunity estimator because Allison was one of those people recently that said, "You know, I found this to be a really interesting sort of tool." And I think that one of the points Jordan made about the fact that you might use it at the beginning to help get your executives engaged, you might use it throughout the course of the project to keep your team updated with what's happening. You might use it at the end of the project to measure your impact. Another point at which you might pull it out and stare at it is when you're stuck, when you're totally stuck and asking yourself, "Why am I in this project? What am I supposed to do? Who got me into this?" If you look at that estimator, everything from the sliding scales of how many infections and how many dollars and how many lives and how many beds to the tab that allows you to go back and look at some of the core literature attached to this work, offers you the opportunity to become reinvigorated on why we're doing this together and why we sometimes struggle and why all of us sometimes get stuck. So, I'm going to ask our operator at this point to open the line, and I'm going to ask Allison or any of our colleagues from Connecticut who might be on the line to queue up to offer your perspective on your use for this because I think that the opportunity estimator, I'm going to say, from the mouths of people who have used it in the field is probably going to have far more relevance than what Jordan and I just talked about. So, operator?

Operator: Ladies and gentlemen, if you have a question at this time, you may do that by pressing star then one on your touchtone telephone. If your question has been answered and you wish to remove yourself from the queue, you may do that by pressing the pound key. Once again, ladies and gentlemen, if you have a question at this time, you may do that by pressing star, then one on your touchtone telephone.

Jordan Duvall: While we're waiting, I quickly wanted to add that we're going to be updating the export feature. So I know that some people have had some problems with it, and we're going to present it in kind of a fancier Word document that will allow you to put in what your unit is and maybe who it's to the attention of and the time period and things like that. And then I was discussing with Della Lin from Hawaii yesterday, potentially coming up with some special reports. And I know she uses it when she doesn't know the case fatality rate for her specific, whether she's aggregating across different hospitals or within a specific area, she presents a best and worst case option and she does that manually. So, we were thinking about providing that also. So, if you don't know the case fatality or if you don't know the cost that you'd be able to hit a button that would be, “Give me the best and worst case.” And that could also be quite powerful in terms of engaging our teams and our team leaders. So, that's coming, and it will be coming soon.

Operator: And we have a question from Allison Hong. Your line is open.

Allison Hong: Hi. Thanks for inviting us to talk about our experience with the opportunity estimator. We introduced it first to our teams on a monthly coaching call, and we walked through how to use it. And a couple months ago when we had our mid-cycle face-to-face meeting, we again demonstrated the calculator and showed how to change the setting and encouraged teams to put in their own data. For instance, if they know their facility cost per CLABSI amount, they could put that in. We also reviewed, and Chris you spoke about this, the reference tab and the source document, and we spent a fair amount of time with the teams and the team leaders talking about the references. They really wanted to understand how the estimates are created and how best that they could speak to it when they share this information with their hospitals. Regarding the sharing of how we use this data and share it, we put our monthly project data together in one facility report, one report by facility. It's transparent. All the data is shared by everyone, and we include the CT by unit, the national rate, and we do it in Excel so everybody can tab over, and I'm talking about the CLABSI rates. For the opportunity estimator, every team got their report, we used their 2009 NHSN data, and each facility and each unit got their own opportunity estimator report based on the 90 percent improvement or 90 percent CLABSI rate reduction. We started out in Connecticut in 2009 with a CLABSI rate of 2, so our goal of 90 percent reduction is in line with the national project goal of a rate of less than 1 per 1,000 central line days. So, we're on track to reach our goal. And if we do, we will have saved four lives, almost $2 million, and 150 ICU days. I'm happy to share that information because recently in Connecticut we just passed legislation to publicly report our facility-level CLABSI data. So, just in summary about the opportunity estimator, it's easy to use and we suggest and we encourage other teams to take a look at it, use it. It helps the teams set their goals and helps them share this data with their leadership in a different way other than just rates. They're really telling a story. Thank you very much.

Jordan Duvall: Thank you, Allison. That's fantastic.

Christine Goeschel: I think we probably will go back and ask you some questions maybe, Allison, in a minute, but I suspect that there might be others on the line who either want to tell their own story of using the calculator or other teams that may want to ask you questions. So, operator, why don't you just go to the next person that's on the line?

Operator: Okay. Our next question comes from Mary Holmes. Your line is open.

Mary Holmes: Yes. I'm representing Francis Health Care in Charleston, South Carolina. And, when I first went to use the opportunity estimator, I did find it a wonderful tool, but what I did with it is I took the information from the opportunity estimator and built it into my already created Excel worksheet where my rates were being generated. And now with all of my infection data, there is an opportunity estimator that goes with each report, and it's just automatically updated as we plug in our numbers. It's just part of the routine report now that people see how much each of the different infection types cost. And they're broken down by unit so each unit can see how many lives they're saving, how much money they're saving. And it is a tool because I'm finding that the nurses out on the floor are amazed at how much one central line infection costs and what it means to their patients as far as how many people die. So, it's been a powerful tool for us.

Christine Goeschel: That's great. And I think as a nurse, myself, one of the things we've talked about this project is that having data on the number of infections that's sometimes new to frontline caregivers, understanding the cost implications is definitely new. When we began the work, it was new to all clinicians and certainly to our finance folks and others, so great way that you're using the tool. Do we have others lined up to share their ideas or ask their questions?

Operator: Our next question comes from Loretta Fauerbach.

Christine Goeschel: Hi, Loretta.

Loretta Fauerbach: Hi. One of the questions I have is when we first did estimated cost for central line infections, we had done studies to determine for NICU and then for pediatrics in general and then adults. Does the calculator allow you to do that? We haven't recalculated those numbers in a while, but just wonder if you have seen any difference based on the population?

Christine Goeschel: That is really a great question, and as with the initial work and most of the work, this is really geared toward the literature on adult input. So, you can't use it and automatically assume that it's the same for either NICUs or PICUs, unfortunately. That is a great question, but the literature is very different, interventions are somewhat different, and that's not our immediate area of expertise, but we'll take some notes on that.

Loretta Fauerbach: Okay. I know that when we did it around 2004, our one population was 11,000, the other one was 9,000, and then the adults were 20,000. Obviously, we've got 7 years of more cost on there, but I just wondered if anybody had relooked at costs since then.

Christine Goeschel: That's a great question. Do we have any other questions or comments from those on the line?

Operator: I'm showing no further questions at this time.

Christine Goeschel: Great. Then I've got a question for Allison, if we can get her back on. I probably have lots of questions, and Sean is leaning into me, so I think he probably has a question as well. Allison, I'm curious because you have in Connecticut one of the first states that we began to work with that had your QIO and your State Health Department part of the work from the get-go, and I'm wondering if you share information from the opportunity estimator or cost level information with them? And if so, what the reactions have been. I'm also curious about the capacity to share this or to have hospitals share this with their medical staff and if you've done that or have any sort of feedback relative to that. So, could you talk a little bit more about how you think some of the hospitals are using it or, if we have hospitals in Connecticut on the line that would be willing to talk, that would be great as well.

Operator: Again, ladies and gentlemen, if you have any questions or comments, you may do that by pressing star, then oneat this time. We have a question from Allison Hong.

Allison Hong: Sorry. Okay. So, Chris, to answer your question, we have a collaborative to reduce infections with our QIO, Qualidigm. It's been going on for a couple of years, so they're involved and stayed involved with us when we started the Stop BSI project. And working with our Health Department, we have a statewide HAI committee with consumer representation and representatives from throughout the Connecticut hospitals, other than the acute care hospitals. So, we're a standing agenda item. We share the information with them, and we just passed legislation to report our facility-level data to the public. They are aware of the opportunity estimator. Qualidigm and our DPH attended our mid-cycle meeting. They've come to all our face-to-face meetings. They listen in on the calls, and they are involved in our coaching calls, our monthly coaching calls. So, we stay in touch with them, and their reaction to the data and the numbers, they had an idea of the cost, but it helps them. And it's empowered us to become more aligned and really continue to row in the same direction, and I know that it just helps all of us by sharing what we know and what we're able to come up with.

And then your second question about sharing with medical staff. The hospital teams are encouraged to share their project data, infection prevention data with their medical staff and the initiatives and incorporate it into their orientation and all of that. But we have a physician executive group that we talk to and many of them are on these teams, so they're involved and they see the data also. But I think the group that's most impacted by the opportunity estimator is the infection preventionists. We've heard for a long time they couldn't get this data, and they really wanted to know what the cases look like. It was very difficult for them to get the financial data in a way that makes sense to share throughout the organization. So the estimator, I've shown it to others outside of the project teams because this is such a great tool for them and we encourage everyone to use it, whether or not they're participating in Stop BSI.

Christine Goeschel: Awesome.

Jordan Duvall: That's interesting to hear about the infection preventionists.

Allison Hong:  They were incredibly happy to see this, and it's so easy to use. And if you know your own numbers, you can plug your numbers in, but it just helps them make the argument and the case for the resources they need and make the argument for what they've been saying for years because it's hard for them to translate the rates, and it's difficult for them to make the argument. Many of them are the major stakeholders. They feel that in quality you have so many competing priorities, a rate of less than 2 or 2, it doesn't seem that important, so it really helps when you see the lives and dollars and infections that you can prevent.

Christine Goeschel: Allison, I mean, that's a crucial point, and thank you so much for bringing that forward. We don't have time to talk about it now. I'm actually sitting here reviewing articles for the Joint Commission Journal on Patient Safety that talk about the executive checklist, the board checklist, and the infection preventionist checklist because we have one for all three groups that we likely need to visit or revisit as we kind of tie together the motivators that seem to help people get engaged and stay engaged. But when you mention infection preventionist, and I know that we've alluded to this in a couple calls lately, Peter did a major session at the APIC meeting a couple of weeks ago on a Monday in New Orleans, and the Association of Preventionist and Infection Control had about 3,000 people at that meeting. And we've talked about the fact that we met with APIC before the meeting. They quickly embraced a project called "I Believe in Zero CLABSIs." They put together a Web site, a series of stickers that infection preventionists could wear at the meeting and get afterwards, a level of commitment for IPs to say, "If my hospital's not involved in this national CLABSI project, I'm going to go back and find out why not and try to encourage them to participate. And if they are involved and I don't know about it, I'm going to find out who the team is in my hospital and see how I can participate." And I think for all of you that are on the line, Allison, your notion that this was a powerful tool for the infection preventionists might be a nice calling card for some of you. If your IPs show up for the first time and say, "What is this that I heard about in New Orleans that Dr. Pronovost was talking about or how do I get involved," clearly we expect you to invite them in warmly because they have expertise that the rest of us don't, and they're a critical part of the team. But I think also, based on your experience, Allison, it might be nice to show them the opportunity estimator, because if they've been curious about this, this is a win for them. As you say, one of the challenges we sometimes face in this work is that infection preventionists have been trying to get us to do the right thing for a long time and haven't always met with success. This notion that it's going to take a team and we all have unique expertise but we all have to be accountable for our part of the action means that they need to be part of a team, but they can't own this, but we can all own the success because it won't happen without everyone. So, very, very cool. That was a great insight. Sean is chomping at the bit here.

Sean: Listening to the conversation is quite striking to me. The conceptual model for this opportunity estimator developed probably over 5 years ago with work with MHA and our group here at QSRG, and then the technical miracles of Jordan turned out to be this kind of really slick kind of tool that allows people to make them much easier to use than other versions. But one of the things that's really striking to me about this tool is that, unlike other things and interventions, when we talk to providers, that seem to elicit some defensiveness or argument about how the evidence and the evidence doesn't apply to us. This kind of tool -- it's amazing to me how it allows people to come together, even though there are remarkable limitations in the estimates that were given. I mean, we're not pretending that this is preventing X number of lives. This is all just based upon best estimates from the literature. As somebody pointed out, this isn't the pediatric patient population and the numbers are very wide. But nevertheless, I've never heard a story about people arguing about the estimates that were used in the calculator the same way that the evidence seems to be divisive between different fields. These kind of numbers about dollars, days, and lives seems to be something that we can all rally around, and it's really an opportunity to bring everybody to the table across different disciplines, and that's one of the really powerful things that I think we're seeing out of this calculator.

Christine Goeschel: Thank you, Sean. I think, I know we're closing in on the hour, but in that regard just an FYI. The Commonwealth Fund asked us for permission to post the estimator or a link to it on their Web site and, of course, we're working with them to make that a reality. I sense that the attention that is focused on this national project, which we know is profound and widespread, is as I'm going to say interested in what we achieve, but also motivated by what we're learning. And I think the use of tools like the estimator, we will look back on this as a really important beginning, but no doubt things will continue to get more sophisticated as each of you look at this and add your perspectives on what would be useful. So -

Jordan Duvall: Yeah, I just wanted to add, Sean was too kind in saying there is some miraculous work going on, but really it's like all the work we're doing. It's based on teams, and there are people before us who helped make it possible and there's everyone that's supporting us now. So, the estimator was 99 percent done before I got my hands on it, and I hope that it can help lots of people do all the mostly important work that we've been talking about onwards.

Christine Goeschel: There are no final words. There is no end to the project. There is no end to the work. There is no end to the need. People died needlessly yesterday from infections that could have been prevented. Don't ever forget that there's a name and a face and a grieving family until we get to zero, which we can do. So, I think that unless there's another person waiting on the line, I would thank everyone for joining us today, and we'll look forward to talking with you again soon.

Jordan Duvall: Thank you, everyone.

Operator: Ladies and gentlemen, thank you for your participation on today's conference. This concludes the program. You may now disconnect. Everyone, have a wonderful day.