Priority of Patient Safety: Good Shepherd Medical Center's Commitment to Quality Care

1. Day 2 Rev. 10-17-12

2. Patient Safety First at GSMC! Rev. 7.30.12

3. Contact • Beth Chrismer: Executive Director Risk Management (1298) • Tina Collins: Patient Safety Officer (1915)

4. National Focus on Patient Safety • Institute of Medicine report – “To Err is Human” (Nov. 1999) • 44,000-98,000 deaths due to medical errors • Annual cost $17B-$29B • Federal Mandate and Regulatory Requirements -Presidential directive, The Joint Commission, Centers for Medicare & Medicaid Services, State regulations

5. Basics of Patient Safety Patient Safety: Actions undertaken by individuals and organizations to protect health care recipients from being harmed by the effects of health care services.

6. The Case for Patient Safety • Patient safety is a critical component of quality • Health care is NOT as safe as it should be • People do not come to work with the intent to hurt patients • We are human therefore mistakes will occur • When mistakes do occur we want there to be no harm • Speak-up for patient safety

7. Patient Safety System

8. Patient Safety First at GSMC! • Patient safety is a priority at Good Shepherd Medical Center.   • Our staff and physicians are committed to improving quality of life and providing safe and healthy surroundings for patients, visitors, and staff.   • Many procedures are in place to protect the well-being of our patients and to secure the best medical outcome possible. • Everyone has a role in patient safety.  

9. The Patient’s Perspective • Don’t hurt me • Heal me • Be nice to me

10. Culture and Safety Culture is the shared values and beliefs of the individuals in the organization (the way we act when no one is looking) Behaviors Outcomes

11. Take Action to Reduce Risk • Proactive: Look for glitches in the system before they result in adverse events. • Reactive: Investigate significant patient incidents.

12. Culture of Safety Root Cause Analysis • We intensely analyze any error that does occur. Based on findings we: • Redesign systems • Test new designs • Educate staff on changes • Follow-up to see if new design is effective

13. Encourage patients, families, staff and physicians to report safety concerns (near misses, close calls, ideas) on the 24/7, anonymous hotline: (BUZZ-2899) • Leave name and number for follow-up • Ideas of merit qualify for recognition or rewards

14. Rapid Response Team

15. Rapid Response Team • The Five Million Lives Campaign by the Institute for Healthcare Improvement encourages healthcare organizations to implement a rapid response team. • In 2006 Good Shepherd implemented a rapid response team. • The goal is to respond to a “spark” before it becomes a “forest fire.” • To prevent deaths in patients who are failing outside intensive care settings.

16. Rapid Response Team • Call Rapid Response anytime you are worried about the patient! • Clinical and non-clinical staff, patients and families can activate the Rapid Response Team. • The team can respond and assist with stabilizing the patient before a cardiopulmonary or respiratory arrest occurs. Call early, Call often

17. The Josie King Story Josie King, an 18 month old little girl, died from medical errors inoneof the best hospitals in our country. Josie was the sisterof Jack, Relly, and Eva and beloved daughter of Tony and Sorrel. She died as aresult of a series of hospital errors and poor communication. Throughthe creation of a patient safetyprogram, it is the King family’s hope to prevent this from everhappening to another patient.

18. Josie King Foundation - Condition “H” (Condition Help) • University of Pittsburgh Medical Center - UPMC Shadyside and  Children’s Hospital of Pittsburgh worked with the King family to develop the nationally recognized model known as Condition H. • Condition H was created to address the needs of the patient/family in case of an emergency or when the patient is unable to get the attention of a healthcare provider in an emergency situation.  The call provides immediate help when: • they feel they are not receiving adequate medical attention; or • if they become concerned with what is happening. • The program was designed to be a safety net for patients. In many cases, it is the family who knows the patient better than we do. • When Condition H is called, a rapid response team arrives • to the patient’s bedside within minutes.

19. Condition “H” (Condition Help) at Good Shepherd

20. Partnering for Safety When patients partner with the health care team, it helps us ensure a safer health care experience for all of us. Patients are encouraged to be actively involved in their own care for safety reasons.    

21. Involve Patients in Care Our Patients-Our Partners: One Team, One Goal A few ways we involve patients in care… • Educate the patient and/or family about hand hygiene, respiratory hygiene, contact precautions • Educate surgical patients about how we prevent adverse events during surgery • Inform patients/families how they can report safety concerns by calling Condition H, Patient Safety Hotline (BUZZ), Guest Relations or The Joint Commission

22. 2013 National Patient Safety Goals • The purpose of the Joint Commission’s National Patient Safety Goals (NPSGs) is to promote specific improvements in patient safety. • The goals are revised on an annual basis and highlight problematic areas in health care and describe evidence and expert-based solutions to these problems. • By addressing problems, organizations can promote patient safety and prevent sentinel events. • A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury.

23. 2013 National Patient Safety Goals Goal 1 Identify Patients Correctly Goal 2 Improve Staff Communication Goal 3 Use Medicines Safely Goal 7 Prevent Infection Goal 15 Identify Patient Safety Risks - find out which patients are most likely to try to commit suicide. UNIVERSAL PROTOCOL: Prevent Mistakes in Surgery Note: Some goals and requirements appear to be misnumbered or missing from the numerical sequence. This in not a typographical error. Some goals do not or no longer apply to hospitals and therefore have not been included.

24. Improve the Accuracy of Patient Identification • To make sure the right person is receiving the intended care, treatment, and services we must use at least two patient identifiers. • Name • Birth date When confirming a patient’s name, staff members should not state the name and ask the patient to confirm it. Instead, staff members should ask the patient to state his or her name and birth date.

25. Reduce the Risk of Healthcare-Associated Infections CDC Guidelines • Alcohol-Based Hand Sanitizer • when hands are not visibly soiled • apply to palm of hand and rub hands together covering all surfaces of hands and fingers until hands are dry • Soap and Water • when hands are visibly soiled • patient has Clostridium Difficile (C-Diff) • after going to the restroom • before eating • at least a 15-second scrub • Gloves • the use of gloves does not eliminate the need for hand hygiene • and hand hygiene does not eliminate the need for gloves

27. Fall Facts - Did you know? • Q - When do most patient falls occur? • A- Within the 1st 24 hours of being admitted. • Q - Who do you think is most likely to fall? • A- age group (50-59) • Q - When do the highest numbers of falls occur? • A- 1-4 am, 10am, shift change @7pm • 21% of falls here are when a patient is getting off of a chair or commode.

28. Fall Prevention • Patients at risk for falls have a yellow “Fall Risk” armband applied and a magnet placed outside the patient’s door. • The patient receives a pair of treaded socks. • All efforts are made to move the patient as close as possible to the nurses desk. • Family or friends are encouraged to stay with patient, if unable may consider a sitter. • Communicate “at risk” patients during patient report and hand off between units.

29. Morse Fall Scale – Assessing the fall risk:

30. Tools for Communication of the Fall Risk Patient - FALL RISK

31. Tools for Communication of the Fall Risk Patient -

32. Ok, now what can I do? Going In/out of rooms – look at magnets to recognize patients that are high fall risk….and.. • “Call Before You Fall” (remind the patients) • Be mindful of getting assistance for these patients if they are trying to get OOB or if in the hallway on their own

33. Is Everybody’s Business Questions?

34. Medical Error Reporting The Medical Error Hotline is a voicemail line available 24 hours a day providing complete anonymity. Employees may use this line to report concerns regarding a medical error was not documented, reported or addressed appropriately. 903-315-5053

35. Variance Reporting Rev. 7.30.12

36. Variance Reporting Hospital employees and medical staff members participate in a hospital wide variance reporting program. Types of Variance Reports: • Falls – Fall Safety Report • Medication Related – Medication Safety Report • Other occurrences not in the above categories – Variance Report

37. Variance Reporting • Variance Reports are to be initiated by hospital staff members or employees involved in or identifying occurrence. • All questions or sections of the report must be completed. • Descriptions should be brief, factual and objective. • Patients, visitors and employees who sustain injuries will receive medical attention. • On-line system allows anonymous • reporting.

38. Variance Reporting • Variances are reported directly from the occurrence area to the • supervisor, manager or director. • Managers should investigate pertinent issues reported with a brief • summary in the online-system • Variance Reports will be trended and reviewed by Risk Management • and Patient Safety Officer. • Variance Report Forms are found on GSnet • Variance Reports are never to be duplicated.

39. Variance Reporting

40. Variance Reporting Examples of occurrences that should be reported on the Variance Report: • Mishaps due to faulty/defective equipment • Unexpected adverse results of professional care or treatment – death, brain damage, physical loss or impairment, etc. • Unprofessional, threatening or inappropriate conduct of health professionals or employees • Patients leaving against medical advice • Thefts, burglaries and vandalism on hospital premises

42. Impaired Provider Rev. 7.30.12

43. Impaired Provider • What is impairment? • The inability to “practice with reasonable skill and safety” because of: • Physical illness or condition • Mental disorder • Alcohol or drug abuse • Disruptive behavior • Sexual misconduct/boundary violations • Burnout

44. Impaired Provider • Examples of disruptive behavior: • Bullying or demeaning behavior • Sexual harassment • Abusive treatment of patients or staff • Profanity or disrespectful language • Repeated violations of rules and policies • Physical attacks, hitting, pinching • Improper comments/illustrations in medical record • Threatening to get someone fired

45. Impaired Provider • Healthcare Practitioner Code of Conduct • Provides guidance to ensure work is done in ethical manner • Also referred to as Code of Ethics

46. Impaired Provider • Reporting impaired practitioners and disruptive behavior: • Document specific examples and patterns of disruptive behavior • Anyone may report an impaired provider or disruptive behavior to Executive Management • Complaints are investigated by Human Resources • Executive Management may identify involved practitioners to the Committee on Physician Health (CPH) • Identity of reporting individual kept anonymous unless individual gives permission to disclose • Retaliation against reporting individuals is • grounds for immediate referral to the • Executive Committee for corrective • action.

47. Safety Sense:Occupational Injury Benefit Plan Rev. 7.30.12

48. What is SAFETY SENSE? • Good Shepherd Health System (GSHS) DOES NOT have workers’ compensation insurance coverage for work-related injuries • GSHS is a “non-subscriber” to workers compensation, and does provide medical, death, dismemberment and wage replacement benefits to employees who sustain injuries or occupational diseases in the course and scope of their employment. • The GSHS plan is called SAFETY SENSE

49. New Plan Effective Aug. 17, 2009 • Our new plan was effective 8/17/09 and provides similar benefits to workers • Medical care for injured employees will be provided at the GSMC Occupational Medicine Clinic. GSMC Emergency Dept. is for true emergencies. • Injuries must be reported within 24 hours of occurrence using the Accident Investigation Report • A urine drug screen is required for injuries that need medical treatment.

50. SAFETY SENSE: Benefits Available • Medical care at Occupational Medicine, specialty referrals, therapy, and diagnostic testing, as needed, through Occ Med provider. • Light duty accommodations for employees placed on restricted duty • Wage replacement at 75% of salary for employees taken off of work after 32 hours of lost time.