NQF Safe Practices and Survey Update

1. NQF Safe Practices and Survey Update April 18, 2008 FH PSO Call

2. NQF Safe Practices and Survey Update Objectives: • Discuss updates to Safe Practices and the NQF Survey • Review timeline for Safe Practice update and NQF Survey reporting

3. Criteria for Inclusion: Safe Practices • Specificity. The Safe Practice must be a clearly and precisely defined process. • Benefit. If the Safe Practice were more widely utilized, it would save lives endangered by health care delivery...or reduce the likelihood of a serious reportable event. • Evidence of effectiveness. There must be clear evidence that the Safe Practice would be effective in reducing patient safety events. • research studies • experiential data • research findings or experiential data from non-healthcare industries that should be substantially transferable • Generalizability • Readiness

4. Review Status NQF Safe Practices for 2008 Update

5. Light Edits: • SP 1: Creating and Sustaining Culture, • Leadership Structures and Systems • Culture Surveys • Teamwork • Risk and Hazard ID and Mitigation • SP 2: Consent • SP 3: End of Life • SP 5: Nursing Workforce • SP 6: Direct Workforce • SP 7: ICU • SP 8: Critical Care Information • SP 9: Order Read-Back • SP 10: Labeling Studies • SP 11: Discharge Systems • SP 12: Safe Adoption of CPOE • SP 13: Abbreviations • SP 15: Pharmacist Role • SP 16: Standardizing Medication Labeling and Packaging • SP 17: High Alert Medications • SP 18: Unit Dose Medications • SP 20: CVC BSI Prevention • SP 22: Hand Hygiene • SP 24: Evidence Based Referrals • SP 25: Wrong Site, Wrong Procedure, Wrong Person Surgery Prevention • SP 26: Perioperative MI/Ischemia Prevention** • SP 27: Pressure Ulcer Prevention** Moderate Edits:SP 4: DisclosureSP 14: Medication ReconciliationSP 19: Prevention of Aspiration and VAPSP 21: Surgical Site Infection PreventionSP 23: Influenza PreventionSP 28: DVT/VTE Prevention** SP 29: Anticoagulation Therapy** SP 30: Contrast Media Induced Renal Failure Prevention New Safe Practices: MDRO: MRSA/CDAD Catheter-associated Urinary Tract Infection Hand-offs – Handovers Second Patient Organ Donor-ship Pediatric Imaging Serious reportable events: Falls, Restraints Glycemic Control Reliable surgical care

6. Moderate Edits:SP 4: Disclosure– Evolving practice SP 14: Medication Reconciliation –JC updatesSP 19: Prevention of Aspiration and VAP –Care of Ventilated PatientSP 21: Surgical Site Prevention – Normothermia potential removalSP 23: Influenza Prevention –Align with CDC 2006 Immun. updateSP 28: DVT/VTE Prevention –Align with ACCP Anti-thrombic 9th guidelines/NQF measures SP 29: Anticoagulation Therapy –Align with TJC NPSG 3ESP 30: Contrast Media-Induced Renal Failure Prevention Update for Gadolinium Adverse Event (NFS)

7. Committee and Subject Matter Expert Work Sessions • Updates to Practice/Additional Specifications of Existing Practices. • Updates to non-Practice narrative elements of the report. • Updates to evidentiary base and citations. • Preparation of new Practice formulations. • Web-Tele-Conference Calls • Scheduling of full committee briefings by subject matter experts. • Audio and multimedia recording and streaming for committee follow-up viewing. • Committee discussions and recommendations. • Final Report • Keep structure the same • Lightly Edited Text • Updated References • Cross-walk Tables • Corrections and Clarification • Care Setting Clarification • Measures To Be Considered • Add Linkages NQF Safe Practice Timeline Q1 2008 Q3 2008 Q2 2008 Q4 2008 Jan Feb Mar April May June July Aug Sept Oct Nov Dec NQF Mtg Appeal Period Public Review SME work March 26-28 Board Approval Fall 2008 NQF Committee March 25 Work Session Completed Work Product (July 15) Call for Nominations Call for Practices May 1 Edits Safe Practice Published Report Softcopy Jan 2009 Revisions

8. New Safe Practices • How are they selected? • Public call for new practices thru NQF • Crosslink with CMS Hospital Acquired Conditions/ Present on Admission Indicators • TJC NPSG 2009 plan • New literature for life saving interventions

9. CMS Hospital Acquired Conditions and Present on Admission Indicator: No outcome, No income • Payment implications October 1, 2008 • Catheter Associated Urinary Tract Infection • Vascular Catheter Associated Infection • Surgical Site Infection – Mediastinitis after Coronary Artery Bypass Graft (CABG) Surgery • Considerations for FY2009 • Ventilator Associated Pneumonia • Staphylococcus aureus Septicemia • Further analysis (AKA coming soon): • Methicillin-resistant Staphylococcus aureus (MRSA) • Clostridium difficileAssociated Disease (CDAD)

10. Multi-Drug Resistant Organisms Prevention: TJC 2009 NPSG 7C • Consistent with SHEA/IDSA taskforce implementation guidelines for HAI prevention • Coming April/May 2008 SHEA journal • Overarching requirements • Educate HCW about MDRO • Measure MRSA/CDAD rates, monitor compliance with best practices, evaluate effectiveness • Provide MRSA/CDAD infection rate data and prevention outcome measures to key stakeholders • Educate patients/families about MRSA/CDAD prevention http://www.jointcommission.org/NR/rdonlyres/5928FA30-6BAB-4017-8DF6-5545E5470154/0/09_Hospital_NPSG_FR.pdf

11. TJC NPSG: MRSA Requirements • Risk assessment • Hand hygiene (Safe Practice 22) • Contact precautions • Clean/Disinfect equipment and environment • MRSA surveillance program • Laboratory alert system for identification • Readmit or transfer alert system for MRSA+

12. TJC NPSG: CDAD Requirements • Risk assessment • Hand hygiene (Safe practice 22) • Contact precautions • Clean/Disinfect equipment and environment • CDAD surveillance program

13. Catheter Associated Urinary Tract Infection Prevention • Urinary tract infection is the most common hospital-acquired infection; 80% of these infections are attributable to an indwelling urethral catheter. • 12-16% of hospital inpatients will have a urinary catheter at some time during admission . • The daily risk of acquisition of urinary infection varies from 3% to 7% when an indwelling urethral catheter remains in situ. • Urinary tract infection is the most important adverse outcome of urinary catheter use. Bacteremia and sepsis may occur in a small proportion of infected patients. • Morbidity attributable to any single episode of catheterization is limited, but the high frequency of catheter use in hospitalized patients means the cumulative burden of catheter-acquired urinary infection is substantial.

14. Catheter Associated Urinary Tract Infection Prevention • Safe Practice • Prevent CAUTIs by implementing catheter use, insertion, and maintenance practices. • Additional Specifications • Provide and implement written guidelines for catheter use, insertion, and maintenance • Develop and implement facility criteria for acceptable indications for indwelling urinary catheter use. • Indications for indwelling urethral catheter use are limited, and include: • Peri-operative use for selected surgical procedures • Urine output monitoring in critically ill patients • Management of acute urinary retention and urinary obstruction • To assist in pressure ulcer healing for incontinent residents • As an exception, at patient request to improve comfort • Ensure that only trained, dedicated personnel insert urinary catheters • Ensure that supplies necessary for aseptic technique catheter insertion are available • Implement a system for documenting in the patient record: indications for catheter insertion, date and time of catheter insertion, individual who inserted catheter, and date and time of catheter removal • Include documentation in nursing flow sheet, nursing notes, or physician orders. • Documentation should be accessible in the patient record and recorded in a standard format for data collection and quality improvement purposes. • Electronic documentation that is searchable is preferred, if available.

15. Handover • The phrase “hand-off/handover communication” refers to a real-time process of passing patient/client/resident-specific information from one caregiver to another or from one team of caregivers to another for the purpose of ensuring the continuity and safety of the patient/client/resident's care. • The critical information shared often includes the patient’s current condition, ongoing treatment, recent changes in condition, and possible changes or complications. • Examples include nursing change-of-shift report; physician sign-out to a covering physician; anesthesia provider or circulating nurse report to the PACU staff; ED staff communication with staff at a receiving facility when a patient is transferred. • The safety of the handover process is often characterized by communication failures and environmental barriers. (Arora 2006, Vol 2003, TJC-NPSG 2)

16. Handover • Safe Practice: • Establish effective communication among caregivers. • Proposed Additional Specifications: • Standardized protocols for handovers are tailored to discipline and organization • A standardized approach should identify the following items: • The “hand-off” situations that it applies to • Who is, or should be, involved in the communication • What information should be communicated, for example, • Diagnoses and current condition of the patient/client/resident • Recent changes in condition or treatment • Anticipated changes in condition or treatment • What to watch for in the next interval of care • Opportunities to ask and respond to questions • When to use certain techniques (repeat-back; SBAR) • What print or electronic information should be available • Develop standard process for handover using process mapping to describe and analyze how an individual clinician interacts with the system, as well as, others in the system • Build a checklist of critical patient content • Discuss implementation strategies with interdisciplinary team and leadership • Plan for dissemination and training • Develop a plan for monitoring and evaluation • Detect and correct vulnerabilities and gaps in the handoff process

17. Care of The Second Patient • Safe Practice • Implement a facility wide strategy for the support of the caregiver following an unintentional medical error or near miss. • Additional Specifications • Facility creates a formal plan with responsibility assigned for supporting caregivers involved in unintentional medical error or near miss. • Formal training of all staff • Follow the 5 rights of the second patient: • Just Culture • Respect • Understanding and Compassion • Supportive care • Transparency and Opportunity to Contribute

18. Organ Donorship • Based on HRSA Collaborative • 98,000 candidates on waiting list

19. Pediatric Imaging • Safe practice: • Image Gently ™ -- "Child-size” the radiation dose delivered to pediatric patients. • Additional Specifications: • Reduce or "child-size" the amount of radiation used. • Scan only when necessary. • Scan only the indicated area required to obtain the necessary information. Protocols in children should be individualized. • Scan once; single phase scans are usually adequate in children.

20. Serious Reportable Events Crosswalk • Incorporate serious reportable events into the safe practices • Create individual safe practices where appropriate • Example: Falls, Restraints • Update risk mitigation to include SREs that cannot stand alone as a safe practice

21. Glycemic Control • Glycemic control is part of surgical site infection prophylaxis. • Nationally healthcare institutions have struggled with appropriate management of glucose. • This safe practice will focus on housewide implementation strategies to control glucose for all patients.

22. What’s New in 2008: The Leapfrog Hospital Survey

23. Update on LFG/ TMIT - 2008 Public Reporting Of 13 SPs LFG Targeted Hospitals Transparency Index Required H LFG 13 Safe Practices H Data Public TMIT High Performer 27 SPs Voluntary TMIT 14 or 27 Safe Practices H H Confidential Practice & Research Feedback H

24. ‘08 LFG Survey Changes 13 Safe Practices Publicly reported by LFG • Safe Practice 1 (elements 1, 2, 3, and 4) – Culture of Safety • Safe Practice 2 – Informed Consent • Safe Practice 3 – Life Sustaining Treatment • Safe Practice 5 – Nursing Workforce • Safe Practice 8 – Communication of Critical Information • Safe Practice 10 – Labeling of Diagnostic Studies • Safe Practice 11 – Discharge Systems

25. ’08 LFG Survey Changes (Cont’d) 13 Safe Practices Publicly reported by LFG • Safe Practice 14 – Medication Reconciliation • Safe Practice 19 – Prevention of Aspiration and Ventilator-Associated Pneumonia • Safe Practice 20 – Central Venous Catheter- Related Bloodstream Infection Prevention • Safe Practice 22 – Hand Hygiene • Safe Practice 28 –DVT/VTE Prevention* • Safe Practice 29 –Anticoagulation Therapy* * Exemption approved based on Taskforce Feedback

26. Changes to TMIT Survey • 14 Safe Practices for ‘08 TMIT voluntary report Survey* • Focus on Performance Improvement Activities • Potential Targets for Exemption • SP# 26, Periop MI Prevention** • SP# 27 Pressure Ulcer – Pending Discussion with Taskforce * Compulsory if organization wants to be considered for “Top Hospitals” **Exemption approved based on current NQF SP report

27. Pediatric Taskforce Recommendations for 2008 LF Survey • Safe practices should not be included for pediatric organizations LF Survey • DVT/PE • Anticoagulation • Perioperative MI • Pressure ulcer under discussion • Taskforce Next Steps • Scheduling of taskforce subcommittee briefings by subject matter experts. • Committee discussions and recommendations for current and new Safe Practices. • Final Report • Updated Pediatric References • Corrections and Clarification • Care Setting Clarification • Measures/Research To Be Considered • Add Linkages to tools/resources Leapfrog Survey Timeline Q1 2008 Q3 2008 Q2 2008 Q4 2008 Jan Feb Mar April May June July Aug Sept Oct Nov Dec Develop Draft for 2009 SP/LF survey Leapfrog Survey LF Survey deadline June 30 LF Survey release April 1 Pediatric Taskforce recommendations July 15 Public reporting results