Author(s): Marylois Lacey, RN
Deputy Quality Management Officer
Department of Veteran Affairs VISN 7

Dr. Lacey has a tenured history as a mental health practitioner and advocate. Her most recent experience is as the Quality and Patient Safety Consultant for Anesthesia, Eye, Dental and Operative Care Line(s) at the Michael E. DeBakey VA Medical Center in Houston, TX. Dr. Lacey was responsible for direct program coordination and evaluation of OIG, Joint Commission, National Hospital Quality Disease Specific Reporting Measures and External Peer Review Program. Dr. Lacey is also an advocate for Mental Health Parity and changing the face of health care disparities in the private, public and federal sector. To that end, she has surveyed psychiatric and rehabilitation facilities across the Southern and Mid-West Regions as a contractor for the Centers Medicare and Medicaid (CMS). In her role as CEO of Eastern Missouri Psychiatric Centers Dr. Lacey advocated for full practice authority for advanced practice nurses. She also served on the Governor's Task Force for Mental Health to develop policies and processes to redesign access to Missouri's mental health system. Dr. Lacey earned her BSN/FNP from the University of Arkansas Medical Sciences, Clinical Nurse Specialist/MSN from the University of Central Arkansas, and PhD in Health Systems from the University of Missouri-St. Louis. She was awarded the Mary Reardon Cass Nursing Research Award from the University of Missouri St. Louis. Dr. Lacey will join the VISN 7 Quality and Patient Safety staff as the Deputy QMO February 13, 2022.

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Competency Domain: Performance & Process Improvement

Description: Deployed system redesign lean principles and Change Management strategies to move key stakeholders from buy-in to ownership were used effectively to roll-out best practice management of C-diff in acute care and nursing home community living centers (NHCLC). Reduction in C-diff rates demonstrated a challenge because the denominator was small so the slightest increase in numerator influenced the overall performance matrix. From FY19 - FY20, the C. diff rate increased from 5.16% to 7.24% in acute areas and from 1.6% to 2.8% in the NHCLC. These rates exceeded the internal and community C-diff rates for acute (4.89) and NHCLC (0.00). Problem: Gap analysis and process map of current state reflected inconsistent ordering of screening, Bristol scale not followed and difficult to access, inconsistent process for terminal room cleaning, inability to differentiate carrier vs. active infection, variation in knowledge and role of C-diff management in all disciplines. Measurement: VA Community Care Compare (VAC3) Acute Care rate of hospital onset C-Diff. NHCLC resident onset of c-diff per 10,000 bed days of care. Limitations were PCR versus 2 step testing process. A control chart was used to evaluate internal best and community comparison for improvement points and stability of processes. Analysis: A Pick Chart was used to prioritize impact and effort of pre-posed interventions. Pre-post test, algorithms to facilitate decision making along with just in time re-teaching and evaluation were the hall marks of the methodology. Basics statistics were used to determine outcomes and reinitiating of the feedback loop. Implementation: Used huddle boards to create the climate of 'ownership', developed standardized order set, badge buddy Bristol scale, RN C-Diff assessment note, standardized physician and direct care staff education, amended Lab contract to add second of EIA Toxin Testing, revised EMS cleaning process and deployed moon beams back to designated units. Results/Discussion VA Community Care Compare (VAC3) Acute care rate of hospital onset C-diff improved FY2022 (5.47) to FY2023 (0.00). NHCLC resident onset C-diff rate FY2022 (0.74) to FY2023 (0.32). The improved process was handed over to the Process Owner after 90 days of sustainment. HAI-infections are included on the C-suite dashboard.

Evaluation: Complete Poster Evaluation