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Laying a “SAFE” Foundation. 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: Wrong Body Part Surgery
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Laying a “SAFE” Foundation Julie Apold Mickey Reid Minnesota Hospital Association
MHA Calls-to-ActionBrief 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: • 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
Roadmap Work Group • Danielle Abel Lakewood Health Center • Mary Ellen Bennett Hennepin County Medical Center • Jane Harper Minnesota Department of Health • Sheila Higbe Olmsted Medical Center • Jane Hirst LifeCare Medical Center • Lindsey Lesher Minnesota Department of Health • Vicki Olson Stratis Health • Kate Peterson Stratis Health • Gail Pries Gillette Children’s Specialty Healthcare • Jean Rainbow Minnesota Department of Health • Mickey Reid Minnesota Hospital Association • Linell Santella Park Nicollet Methodist Hospital • Cindi Welch Essentia Health • Boyd Wilson HealthEast Care System
Roadmap Structure • SAFE • Building Blocks • Infection-specific Gap Analyses
SAFE = S (Safety Teams/Org Structure) • Action 1: Secure endorsements and resources for HAI Prevention Program • Leadership: • Endorses the work • Clearly communicates goals • Regularly reviews progress toward goals • Supports adding resources as appropriate • 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) • With designated time!
SAFE = S (Safety Teams/Org Structure) • Action 3: Identify gaps and develop action plans • The interdisciplinary team: • Reviews and updates the HAI prevention program • Reviews data results at least quarterly and identifies strengths and opportunities • Develops a plan to prioritize and address improvement opportunities • 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 • 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: • When to stop the line • How to stop the line (verbal/non-verbal cue) • The chain of command to follow if not supported in stopping the line • 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, Background, Assessment, Recommendation (SBAR); isolation signage • A structured hand-off process (what should be communicated; how?) • During shift change • Between departments/units • To other facilities
SAFE = F (Facility Expectations) • Action 4: Disclose unanticipated events • Promptly inform patients/families when an 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 • Cultural, language, hearing impairment, health literacy • Educated on their role and what they can expect to see from caregivers • Assess patient /families’ level of understanding e.g., teach back • Encourage “speaking up”
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
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 • January 1st, 2013 for IPPS hospitals • Determine approach for non-IPPS facilities: • A staggered approach • Allow time for training and support of NHSN system • Consider attestation for low volume procedures • Tentative goal of first reporting for non-IPPS hospitals will be starting July 1st, 2013
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