Quality and Patient Safety

1. Quality and Patient Safety Roberta Monson, MD Jo Ellen Austin, PharmD Judi McGuire, RN

2. We are preparing for our triennial JCAHO visit which will occur this fall. • We need everyone’s help in order to have a successful survey. • Quality of care and Patient safety will be the # 1 focus.

3. JCAHO Tracer Methodology • Review all processes by tracing patient care • Current patients will be selected • Patients will be chosen by clinical services • Information will come from staff and patient interviews • Repeat visits are possible

4. Documentation Issues • History and Physical • Post Op/Post procedure notes • Legibility/Physician identification • Discharge Planning

5. Medication Issues • Verbal orders – read back • Abbreviations – QUIT AM • Standard concentrations • Secure storage • Medication errors/Adverse Drug Events • Medication Order Review

6. Quality Improvement Methodology • Plan • Do • Check • Act

7. Everyone in the organization is expected to know and meet these goals. JCAHO requires 100% compliance with the safety goals. National Patient Safety Goals

8. Accurate patient identification • Improve the accuracy of patient identification • Use at least two patient identifiers (our policy requires name and birth date) to verify patient ID when performing treatments or procedures.

9. Effective Communication • Improve the effectiveness of communication among caregivers • Request a “Read-back” when giving verbal or telephone orders or perform one when receiving critical value test results.

10. Effective Communication Do not use the following abbreviations in orders: • U (for unit) • IU (for international unit) • O.D or Q.O.D (for every day or every other day) • Trailing or leading zero (X.0 mg or 0.X mg) • MS, MS04 or MgS04 (morphine sulfate, mag sulfate) • Ug (for microgram) • A (for ear) • Investigational “nicknames” for commercially available products, such as 5FU

11. Safe Medication Use • Improve the safety of using medications • Use the standardized drug concentrations available in e-chart. • Be alert to prevent errors involving look-alike or sound alike (SALAD) drugs.

12. Preventing Infections • Reduce the risk of health-care acquired infections • Comply with CDC hand hygiene guidelines • Use Central Venous Line protocols to avoid infections • Treat all identified cases of unanticipated death or permanent injury due to health-care acquired infection as sentinel events.

13. Reconciliation of medications • Work to accurately and completely reconcile medications across the continuum of care • All home meds are addressed on admission. • At time of transfer to another unit meds are reviewed and documented. • At discharge consider home and all new medications. • Meds are communicated to patient and any care providers.

14. Universal Protocol • Eliminate wrong site, wrong side and wrong procedure surgeries or interventions • Verification of consent and any supporting information, such as x-rays prior to procedure • Site marking when indicated • “Time out” when all are present • Also applies to bedside procedures

15. Universal Protocol • “Time out” includes: • Right patient • Right procedure • Right positioning • Right side and site • Any special equipment needed, correct implants, tubes or catheters • Use the procedure note form to assist with documentation.

16. National Quality Measures • JCAHO and the Center for Medicaid and Medicare Services (CMS) have joined forces in evaluating us on accepted best practices for the following diseases: • Congestive heart failure • Acute Myocardial infarction • Pneumonia • OB and Pregnancy related

17. AMI Measures • Aspirin at arrival • Aspirin at discharge • ACE inhibitor for LVSD • Smoking cessation • Beta blocker at arrival • Beta blocker at discharge • Time to thrombolysis less than 30 minutes • Time to PTCA less than 120 minutes

18. Heart Failure Measures • LVF assessment documented • ACEI or ARB for LVSD • Smoking cessation (smoker within past 12 months) • Discharge teaching includes: (must include all) • Home mediations • Activity • Diet • Follow up care • What to do if symptoms worsen or reoccur • Weight monitoring

19. Pneumonia Measures • Oxygenation assessment • Blood culture prior to antibiotics • Antibiotics within 4 hours of arrival time • Smoking cessation • Pneumococcal screening and vaccination

20. Pregnancy related Measures • Inpatient neonatal mortality rate • Vaginal birth after c-section (VBAC) rate • Rate of third or fourth degree perineal laceration • These measures are only reported to JCAHO

21. Results are now available to the public at www.medicare.gov/hospital

22. 2nd quarter 2004 data

23. And at the JCAHO web site

25. We need your help.