Transcript Slide 1

Laying a “SAFE”
Foundation
Place picture here
Julie Apold
Mickey Reid
Minnesota Hospital
Association
MHA Calls-to-Action
Brief History
 AHE Law went into effect July 2003
 Report any of the 28 National Quality Forum
Serious Reportable Events
 Event types with highest # of reports:
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Wrong Body Part Surgery
Retained Foreign Objects
Falls
Pressure Ulcers
Focused Approach to Improvement
 Focus on top events
• Determine Best Practices
• Implement Best Practices
 Convened Advisory Groups
• Reviewed National and Local Best Practices
• Reviewed AHE Data
• Developed Implementation Best Practices
Patient Safety Roadmaps
MHA Statewide Calls-to-Action
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Safe SKIN
Safe FALLS
Safe SITE
Safe Count
Safe Account
Roadmap Work Group
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Danielle Abel
Mary Ellen Bennett
Jane Harper
Sheila Higbe
Jane Hirst
Lindsey Lesher
Vicki Olson
Kate Peterson
Gail Pries
Jean Rainbow
Mickey Reid
Linell Santella
Cindi Welch
Boyd Wilson
Lakewood Health Center
Hennepin County Medical Center
Minnesota Department of Health
Olmsted Medical Center
LifeCare Medical Center
Minnesota Department of Health
Stratis Health
Stratis Health
Gillette Children’s Specialty Healthcare
Minnesota Department of Health
Minnesota Hospital Association
Park Nicollet Methodist Hospital
Essentia Health
HealthEast Care System
SAFE from HAI Roadmap
Roadmap Structure
 SAFE
 Building Blocks
 Infection-specific Gap Analyses
“SAFE”
SAFE = S (Safety Teams/Org Structure)
 Action 1: Secure endorsements and resources
for HAI Prevention Program
• Leadership:
o Endorses the work
o Clearly communicates goals
o Regularly reviews progress toward goals
o Supports adding resources as appropriate
o Designates a senior leadership sponsor
SAFE = S (Safety Teams/Org Structure)
 Action 2: Promote HAI prevention
representation/champions/liaisons
throughout the facility
• Regular Interdisciplinary team
• Champions
• Liaisons
• Ad-hoc for specific projects
• Designated coordinator(s)
o With designated time!
SAFE = S (Safety Teams/Org Structure)
 Action 3: Identify gaps and develop action
plans
• The interdisciplinary team:
o Reviews and updates the HAI prevention program
o Reviews data results at least quarterly and identifies
strengths and opportunities
o Develops a plan to prioritize and address improvement
opportunities
o Commissions subgroups as needed
SAFE = A (Access to Information)
 Action 1: Track progress on process and
outcome measures
• Observational audits
• Inter-rater reliability
• Capture infection event details
SAFE = A (Access to Information)
 Action 2: Review and analyze data for
improvement opportunities
• Routinely review and analyze data
• Track progress against established targets
o Run charts, control charts, dashboards, scorecards
• Prioritize and act upon identified issues
SAFE = A (Access to Information)
 Action 3: Data is shared on a regular basis to
promote system-wide learning and
transparency
• Share vertically and horizontally
• A story with worth 1,000 data points
SAFE = F (Facility Expectations)
 Action 1: Leadership establishes and
communicates clear expectations
• All staff informed of expectations
• Culture supports speaking up/stopping the line
• The “stop the line” process clearly outlines:
o When to stop the line
o How to stop the line (verbal/non-verbal cue)
o The chain of command to follow if not supported in
stopping the line
o Clear communication to staff from managers and
leadership that staff will be supported if they speak up
SAFE = F (Facility Expectations)
 Action 2: Education for HCP and prescribers
• Orientation
• Annually
SAFE = F (Facility Expectations)
 Action 3: Establish a structured
communication process
• Structured communication tools, e.g., Situation,
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Background, Assessment, Recommendation
(SBAR); isolation signage
A structured hand-off process (what should be
communicated; how?)
o During shift change
o Between departments/units
o To other facilities
SAFE = F (Facility Expectations)
 Action 4: Disclose unanticipated events
• Promptly inform patients/families when an
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unanticipated event occurs that has potential to
contribute to an HAI
Establish who should discuss with the
patient/family and how
Provide training and support to staff on
effective disclosure strategies
Keep patient/family updated
SAFE = E (Engagement of Pts/Families)
 Action 1: Educate and empower patient/
families
• Address any barriers to patient/family
understanding their role in HAI prevention
o Cultural, language, hearing impairment, health literacy
• Educated on their role and what
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they can expect to see from caregivers
Assess patient /families’ level of
understanding e.g., teach back
Encourage “speaking up”
Building Blocks – Hand Hygiene
Building Blocks – Transmission
Precautions
Building Blocks – Antimicrobial
Stewardship
Building Blocks – Injection Practices
Building Blocks – Environmental
Cleaning
Topic Specific Gap Analyses
Topic Specific Gap Analyses
Topic Specific Gap Analyses
Topic Specific Gap Analyses
Topic Specific Gap Analyses
Thresholds
 Each infection topic area will have a process
and outcome threshold
 Thresholds incorporated into the dashboard
and in the Registry home page
 Goal: Assist in prioritizing efforts
 The Patient Safety Registry will automatically
recognize if thresholds are being met and
provide a visual indication
 If exceeding process and outcome thresholds,
visual indication that threshold is met
Thresholds
Healthcare Acquired
Conditions
Healthcare-Associated Infections
Process Measures
SAFE from HAI Roadmap
Outcome Measure
Infection Rates
Thresholds
1) SSI and CAUTI = TBD (per NHSN)
2) VAP and CLABSI = 0
Source
MHA patient safety registry, Calls to Action; NHSN
Criteria
1. ≥90% Safe from HAI Roadmap for 2 consecutive quarters
2. Rates below target
Actions - If criteria met
Monitor rates, if above target, begin quarterly roadmap updates
Actions - If criteria not met
Continued participation and quarterly updates for Safe from HAI
Data Submission Schedule
 HAI Roadmap Data Updates
• Submit quarterly with other roadmap updates
• Baseline due September 30 (Grace-period October 14th)
 Outcome Data
• Setting up agreement with hospitals submitting to
NHSN designating MHA as user-group
Outcome measures
 Current mandated state reporting (through MHA
maintained website)
• VAP bundle
• Central Line Insertion bundle
• Surgical Site Infections (SSI) for Total Knee and Vaginal
Hysterectomy
 Federally IPPS hospitals report through NHSN:
• Central line infections
• SSIs (including colon and abdominal hysterectomy)
• More in coming years
Outcome measures
 Move to align state and federal reporting
• Discontinue reporting through MHA site
• Begin reporting through NHSN
o January 1st, 2013 for IPPS hospitals
• Determine approach for non-IPPS facilities:
o A staggered approach
o Allow time for training and support of NHSN system
o Consider attestation for low volume procedures
o Tentative goal of first reporting for non-IPPS hospitals
will be starting July 1st, 2013
Roadmap Data Submission
Roadmap Data Submission
Roadmap Data Submission
Roadmap Data Submission
Roadmap Data Submission
New Hospital Reports – Action Plan
New Hospital Reports: Progress Report
New Hospital Reports: Section Report
New Hospital Reports: Gap Analysis
Dashboards
 Patient Safety Dashboards are sent to CEOs
quarterly
 Gradual expansion of Dashboard
 HAI Roadmap and Outcome data targeted to
be included in dashboard 4th quarter 2012
Next Step for SAFE from HAI
 Sign-up for SAFE from HAI initiative
• Designate key contact
• Receive access to Patient Safety Registry for data
submission
 Complete SAFE from HAI Baseline by September 30th
• Use Gap Analysis Report to begin addressing gaps
 Participate in Activities
• Listserv (automatically enrolled if in SAFE
from HAI)
• Webinars/educational opportunities
 Update SAFE from HAI Roadmap quarterly
Questions?