Debrief to Dashboard: Driving Data Integrity Through Centralized Surveillance

Session Description: Maintaining data integrity is a critical challenge in healthcare, particularly in the surveillance and reporting of healthcare-associated infections (HAIs). Accurate interpretation of National Healthcare Safety Network (NHSN) definitions for events, such as catheter-associated urinary tract infections (CAUTI), central line-associated bloodstream infections (CLABSI), Clostridioides difficile (C. diff), and surgical site infections (SSIs), is essential to ensuring regulatory compliance and improving patient outcomes.
A large healthcare system identified gaps in the accuracy, timeliness, and validation of HAI surveillance data. In response, it implemented a Centralized Surveillance Program to enhance standardization and elevate data integrity. Centralized Infection Preventionists (IPs), serving as remote subject matter experts, use surveillance tools and electronic data mining systems, to conduct thorough reviews of electronic health records. Working in close collaboration with facility-based IPs, the centralized team verifies surveillance data and ensures alignment with NHSN definitions and reporting requirements.
To support this effort, the system leverages two key internal resource tools: the HAI Monthly Dashboard and weekly HAI debrief numerator reports. These dashboards provide a comprehensive view of performance across the five Centers for Medicare & Medicaid Services (CMS) mandated HAI measures identifying anomalies and opportunities for improvement. Additionally, weekly debrief reports deliver real-time data insights, flagging numerator events for early review. Data from the most recent two months are marked as preliminary and subject to validation before final NHSN submission.
Our multipronged approach consists of centralized IP expertise, collaborative validation, and actionable data tools. This in turn creates a reliable, transparent, and high-performing infection surveillance framework, leading to improved patient outcomes.

Laura Aschenberg

System Director Infection Prevention, CommonSpirit Health

Laura Aschenberg serves as the System Director of Infection Prevention at CommonSpirit Health. In this key role on the National Patient Safety Team, she provides leadership and support to Infection Preventionists across the entire system. Laura also manages a team of seven Infection Preventionists responsible for centralized surveillance of healthcare-associated infections. With a 30-year nursing career, including 22 years dedicated to infection prevention and 20 years as a board-certified professional, Laura brings deep expertise and a passion for designing and implementing system-wide infection prevention programs. She is recognized for her collaborative leadership, strong mentorship, and strategic, solutions-focused approach. Her work consistently fosters a culture of accountability, clinical excellence, and continuous learning.

Rebecca Leach

System Manager Infection Prevention, CommonSpirit Health

Rebecca (Becky) Leach is the System Manager of Infection Prevention at CommonSpirit Health, bringing 15 years of experience as a certified infection preventionist. Her comprehensive approach to infection prevention is rooted in her background in epidemiology and nursing. She has a broad range of experience, having worked in various healthcare settings from tribal nonprofits to academic medical centers. In her current role, Becky is responsible for leading and supporting over 170 infection preventionists across more than 140 CommonSpirit Health facilities. She develops and implements infection prevention programs, policies, and procedures. Becky also plays a key role in operationalizing the Infection Prevention Program's strategic plan and integrating new regulations and guidelines, thereby ensuring current, effective, and compliant strategies for the safety of patients, staff, and visitors.

Amy Huff

Infection Preventionist, Hazel I. Findlay

Amy Huff, RN, CIC, LTC-CIP has worked at Hazel I. Findlay, a Skilled Nursing Facility in Michigan, for 35 years. She began as a Nurse Aide while completing her nursing education and spent 17 years as a floor nurse, Nurse Aide Training Program Instructor, Education Manager, and other managerial roles before stepping into the Infection Preventionist role in 2007. She has served on committees in Disaster Preparedness and Infection Prevention and Control realms. Amy enjoys learning, meeting new people, and mentoring others; she considers her CIC, LTC-CIP, and a-IPC certifications to be essential milestones in her career and encourages her peers to take these important steps. She is an APIC Faculty Member, instructing several courses. She has been a part of her Great Lakes APIC Chapter in the Membership Secretary role and feels honored to have served as a member of the APIC National Conference Committee.