Hospital Associated Infections Data Discussion Paper

Hospital Associated Infections Data Discussion Paper

Hospital Associated Infections Data Discussion Paper

Health care delivery keeps evolving as health care professionals adopt current, evidence-based strategies to improve patient care. To improve outcomes, organizational leaders collect, analyze, and apply data findings to address practice gaps. The gaps can be organization-wide or related to a specific aspect of the health process. Data on ABC Health’s quality analyzes performance in managing hospital-associated infections (HAIs) over five years (2011-2015). The data illustrate the organization’s internal performance and against the national benchmark. It is important to share such data with the organization’s stakeholders since they play a critical role in performance improvement. The purpose of this paper is to discuss the data while focusing on conclusions, trends, and appropriate quality improvement metrics.


Conclusions Drawn from Each Quality Measure

Table 1: ABC Health’s Scores 2011-2015

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Quality Measure

ABC Health’s Scores
2011 2012 2013 2014 2015
SSI: Colon 0.273 0.174 2.219 2.487 3.555
CLABSI 2.845 2.203 3.062 3.063 3.422
CAUTI 2.814 0.827 0.567 0.466
SSI: Hysterectomy 1.148 2.132 2.094 3.697 4.608

From a health perspective, a comparative analysis of data over time helps leaders and health care staff to quantify performance. Analyzing performance guides leaders in decision-making as they develop quality improvement strategies and other performance enhancement strategies. The quality measures’ scores show that infection rates for Surgical Site Infection from colon surgery (SSI: Colon) were the lowest in 2011 at 0.273. Unfortunately, the rates rose gradually up to 3.555 in 2015. A similar trend is visible for Central line-associated bloodstream infections (CLABSI) and Surgical Site Infection from abdominal hysterectomy (SSI: Hysterectomy). However, there is a gradual decline in the Catheter-Associated Urinary Tract Infections (CAUTI) rates, which is encouraging since the infection rates should be as low as possible.

Health care organizations should do everything legal and professional to address issues hampering patient care. HAIs result in poor patient outcomes since they increase morbidity, mortality, and the length of stay in hospitals (Haque et al., 2018; Stewart et al., 2021). Extended stays increase health costs and workload and affect patients’ trust in care providers. The increased workload is a leading cause of burnout among health care professionals, particularly in critical care areas such as the emergency department (Watson et al., 2019). From the data, SSI: Colon, CLABSI, and SSI: Hysterectomy pose a significant risk to patient health due to their increasing rates over time. Accordingly, ABC Health must intensify efforts to reduce the rates as much as possible. Other health care facilities with a similar trend should develop mechanisms to reduce the rates to avoid the adverse outcomes of HAIs in health care delivery.

Trends Seen for Each Quality Measure

Health care organizations should rely heavily on qualitative and quantitative data. Data-based decisions are always rational, and help organizations use minimal resources since they apply evidence-based interventions. Trends over the five years can be a reliable reference point for organization-wide decisions. As illustrated in Table 1, SSI: Colon, CLABSI, and SSI: Hysterectomy are characterized by a progressive increase in infection rates. It is an unfortunate scenario that health care facilities should avoid by all means. Among many causes, issues such as poor hygiene could be a potential cause. Other risk factors include increased visits of patients with co-existing infections, compromised immune systems, and overuse of antibiotics. CAUTI rates have been gradually declining, but it is incorrect to deduce that it does not pose a risk to patients’ health. If the data accurately reflects what happens currently, ABC Health should apply the techniques used in CAUTI management to control the other HAIs.

Comparison with the National Benchmark

Table 2: SSI: Colon rates vs. the National Benchmark

Year 2011 2012 2013 2014 2015
ABC Health’s Score 0.273 0.174 2.219 2.487 3.555
National Benchmark 2.234 2.136 2.219 2.319 2.548


Benchmarking allows organizations to intensify their efforts to achieve better performance. It helps organizations compare their performance to other facilities at the local, state, or regional levels. According to Hibbert et al. (2021), benchmarking in health practice is critical to quality improvement, high efficiency, and satisfactory patient experience. The above table shows that ABC Health performed better than the national benchmark only for two years (2011 and 2012). After that, the score matched the national benchmark in 2013 but worsened in 2014 and 2015. From the data, is right to deduce that the SSI: Colon rates were worse than the national benchmark in the facility. Performing worse than the national benchmark average signifies a huge patient safety concern that requires an immediate intervention.

Table 3: SSI: CLABSI rates vs. the National Benchmark

Year 2011 2012 2013 2014 2015
ABC Health’s Score 2.845 2.203 3.062 3.063 3.422
National Benchmark 2.234 2.089 3.128 3.063 3.422

All HAIs represent a significant patient care problem that requires immediate intervention. From Table 3, it is justified to deduce that CLABSI’s average score over the analysis period matches the national benchmark. Apart from 2011 and 2012, the facility performed better than the national average or matched the national benchmark. Since the primary goal of a health care facility should be reducing HAIs rates despite the national benchmark, interventions in this area are also critical to ensure that patients visiting the facility are free from any risk.

Table 4: CAUTI rates vs. the National Benchmark

Year 2011 2012 2013 2014 2015
ABC Health’s Score 2.814 0.827 Not available 0.567 0.466
National Benchmark 1.879 0.827 Not available 1.089 1.231

Organizations should strive to achieve excellence, and performing better than the national benchmark accurately illustrates the recommended effort. Besides showing excellence in service delivery, a performance better than the national benchmark indicates a commitment to reducing safety risks. From Table 4, it can be accurately deduced that the average infection rate for CAUTI in the analysis period is lower than the national benchmark. Encouragingly, there is a significant gap between the facility’s score and the national benchmark from 2012. Despite ABC Health’s score for CAUTI surpassing the national benchmark in 2011, the situation changed from 2012 to 2015. The change can be a predictor of gradual decline in later years too.

Table 5: SSI: Hysterectomy rates vs. the National Benchmark

Year 2011 2012 2013 2014 2015
ABC Health’s Score 1.148 2.132 2.094 3.697 4.608
National Benchmark 2.133 2.132 2.094 2.512 2.703

ABC Health performed better than the national benchmark only in 2011. In the period that followed, the performance matched the national benchmark (2012 and 2013) and worsened in 2014 and 2015. Worse, it was almost double the national benchmark in 2015. From the performance over time, it can correctly be deduced that the facility’s average score is worse than the national benchmark.

Priority Quality Measures and Rationale

Optimal performance is signified by a lack of patient care issues in health care organizations. Despite the gradual performance in CAUTI infections, some cases are still reported in the facility. As a result, all quality measures should be prioritized so that the organization’s leaders can develop different mechanisms to prevent infections. As previously noted, HAIs are a significant patient risk since they increase morbidity, mortality, and extended hospital stay (Haque et al., 2018). Despite the differences in infection rates, all quality measures contribute to these adverse outcomes in ABC Health. Prioritizing them is crucial to enable the facility to optimize health outcomes as time advances. The guiding principle should be preventing infections and not performing better than the national benchmark.

Quality Improvement Metric and Related Measures

ABC Health can achieve better performance in all quality measures through management support and creative interventions. A suitable quality improvement metric is a quantifiable target that the facility should strive to achieve. Hence, the facility should achieve a 25% reduction in infection rates annually for two years before revising the metric. The most effective way of achieving the quantifiable targets is by integrating evidence-based practice (EBP). According to Chien (2019), EBP allows health care professionals to combine scientific evidence, clinical expertise, and patient preferences to improve care outcomes. Measures to improve care processes, outcomes, and patient experience should be evidence-based. Such measures include improved hand hygiene for infection control, on-the-job training of nurses on sterile techniques, and cleaning the patient care environment (Haque et al., 2020). Patients should also be educated on handling devices such as catheters, and hygiene issues should be reported instantly.

Monitoring the Metric and Using Data for Improvement

The metric can be monitored quantitatively and qualitatively. A suitable quantitative monitoring strategy is a comparative analysis of the monthly reported HAIs cases. It can help providers determine whether there is a gradual reduction in infections as projected. Qualitatively, patients and nurses can be interviewed on care experiences and improvements over time. Observations, surveys, and clinical records can be used as references interchangeably. The data would be used to guide evidence-based interventions, inform nurses about possible risks, and serve as the foundation of current technology adoption. In each case, progressive improvement in patient care outcomes would be the primary objective.


Quality improvement is a standard practice in health care organizations. As a result, all facilities should assess their performance and develop appropriate initiatives to address performance gaps. As discussed in this paper, HAIs are the main problem hampering care at ABC Health, as the various data tables illustrate. Since HAIs have far-reaching consequences on patient care, preventing them should be prioritized. EBP interventions such as improved hand hygiene and patient education can effectively help the facility achieve the desired goals.


Chien, L. Y. (2019). Evidence-based practice and nursing research. The Journal of Nursing Research : JNR, 27(4), e29.

Haque, M., McKimm, J., Sartelli, M., Dhingra, S., Labricciosa, F. M., Islam, S., … & Charan, J. (2020). Strategies to prevent healthcare-associated infections: A narrative overview. Risk Management and Healthcare Policy, 13, 1765.

Haque, M., Sartelli, M., McKimm, J., & Abu Bakar, M. (2018). Health care-associated infections – an overview. Infection and Drug Resistance, 11, 2321–2333.

Hibbert, P., Saeed, F., Taylor, N., Clay-Williams, R., Winata, T., Clay, C., … & Braithwaite, J. (2020). Can benchmarking Australian hospitals for quality identify and improve high and low performers? Disseminating research findings for hospitals. International Journal for Quality in Health Care, 32(Supplement_1), 84-88.

Stewart, S., Robertson, C., Pan, J., Kennedy, S., Haahr, L., Manoukian, S., … & Reilly, J. (2021). Impact of healthcare-associated infection on length of stay. Journal of Hospital Infection, 114, 23-31.

Watson, A. G., McCoy, J. V., Mathew, J., Gundersen, D. A., & Eisenstein, R. M. (2019). Impact of physician workload on burnout in the emergency department. Psychology, Health & Medicine, 24(4), 414-428.


Assessment Description
The purpose of this assignment is to examine health care data on hospital-associated infections and determine the best methods for presenting the data to stakeholders. Use the scenario below and the “Hospital Associated Infections Data” Excel spreadsheet to complete the assignment.


You have been tasked with displaying Centers for Medicare and Medicaid Services (CMS) hospital quality measures data for a 5-year period on four quality measures at your site. After examining the data, identify trends and determine the best way to present the actionable information to stakeholders.


Create a 1500-1650 word paper discussing the data with the stakeholders. Address the following in your paper:

1. What conclusions can be drawn for each quality measure over the 5-year period?
2. What trends do you see for each quality measure over the 5-year period?
3. When comparing each quality measure, is the quality measure better than, worse than, or no different from the national benchmark over time?
4. Based on your examination of the data, which of the quality measures should you prioritize and why?
5. Develop a quality improvement metric and related measures to improve care processes, outcomes, and the patient experience relating to the identified area of opportunity.
6. Explain how you would monitor the metric and use collected data for improvement.

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