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Patient Safety Initiative (PSI): Hospital Survey Protocol

Patient Safety Initiative (PSI): Hospital Survey Protocol. Russ Forney, PhD, MT(ASCP) Licensing & S urveys, Aging Division Wyoming Department of Health (Photos courtesy of Cinderella Forney). Sizing Up the Situation. Adverse events 1 in 3 admissions (2011) HAIs affect 1 in 20 inpatients

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Patient Safety Initiative (PSI): Hospital Survey Protocol

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  1. Patient Safety Initiative (PSI):Hospital Survey Protocol Russ Forney, PhD, MT(ASCP) Licensing & Surveys, Aging Division Wyoming Department of Health (Photos courtesy of Cinderella Forney)

  2. Sizing Up the Situation • Adverse events 1 in 3 admissions (2011) • HAIs affect 1 in 20 inpatients • About 1 in 5 Medicare patients readmitted within 30 days of discharge • 1.8M injuries, $35B in 3 years (08-11) • Survey process has little impact

  3. Partnership for Patients • P4P: focused on improving patient safety in hospitals • Reduce HAC = reduce readmissions • Partners: HHS, FDA, CDC, VA, HENs, QIOs, National and State associations, professional societies

  4. Head scratching…

  5. Patient Safety Initiative (PSI) • PSI emerged from P4P • CMS S&C initiative • Tools for surveyors & facilities • Focus on infection control, discharge planning, and QAPI activities

  6. Approaching a Solution • 4,000 member organizations (“partners”) • Goal: Reduce readmissions • Tools to assist hospitals and surveyors • Common to certification & accreditation (“substantial equivalent”) • Adopted focus: IC, DC, QAPI

  7. Russ goes to Baltimore…

  8. …and so does Pat

  9. PSI & Pilot Surveys • Acute Care Hospital survey process • Emphasize 3 CoPs: • QAPI • Discharge planning • Infection Control • Regulations unchanged, build better surveyors

  10. Initial Impact • Pilot surveys (field training) • No increase in staffing • Tools guide survey process • Tools identify specific tags • Enhance depth, consistency of surveys

  11. Tool-guided Survey Protocol • CoP specific survey tools • Underlying CoP not changed • Better identify noncompliance and “best fit” tag • Target minimum acceptable health & safety standards

  12. Pilot Survey “Rules” • Initiate complaint survey (CMS 2802) • No conditions (other than IJ) • One CoP (tool) per survey • Training in the field (OJT) • Share surveyor tools with facilities

  13. A Matter of Perspective…

  14. The Survey Process • Verify compliance through: • Observation, interview, review • Patient driven protocols • Facility-relevant projects • Hospital-wide processes • Apply the surveyor tools within the existing framework

  15. Wyoming PSI Pilot Surveys • Mountain View Regional Hospital • 13-16 August: Russ, Pat, Janelle, Linda • Infection control surveyor tool • Ivinson Memorial Hospital • 20-22 August: Pat, Tony, Karen • Discharge planning surveyor tool • Lander Regional Hospital • 10-11 September: Russ, Pat, Lori, Larry • QAPI surveyor tool

  16. Infection Control Worksheet • 5 Modules, 42 pages • 2 surveyors x 2 days • Cover all practices to identify & prevent HAIs • Follow patients through procedures & treatments

  17. Infection Control Pilot • More in-depth investigation than current protocol • No “experts”, but similar outcomes • Heavily weighted on processes & monitoring activities • Vertical elements

  18. Discharge Planning Worksheet • 4 Sections, 23 pages • 2 surveyors x 1-2 days • Cover best practices for discharge planning & coordination of care • All healthcare members involved

  19. Discharge Planning Pilot • Planning begins at admission • Ongoing throughout admission • Address patient needs post-discharge • Physician involvement • Results in reduced readmissions

  20. QAPI Worksheet • 6 Parts, 21 pages • 2 surveyors x 1-2 days • Quantitative assessment (data-driven) • Follow specific projects & activities through entire life-cycle • Required elements: med errors, infcont, transfusions, near-miss/adverse events

  21. QAPI Pilot • QAPI is relevant to the hospital • Involvement through the ranks • Data as basis for analysis (CDC) • Interventions & ongoing assessment • All programs, units, & services

  22. CMS Update • 187 pilot surveys, 52 State Agencies • Sep 2011 to Sep 2012 • Less P&P, more observations of activity • Sorting out regulation vs best practice • Links surveyors and staff more closely • Continue in Fiscal Year 2013…?

  23. Who else is in the River…

  24. Wyoming Partners • Mountain-Pacific Quality Health (QIO) • WY Hospital Association • WY Dept of Health • WY HAI Advisory Group • HAI Coordinator • HLS • WY ASC Association (IC initiatives)

  25. Contact: Russ Forney, PhD, MT(ASCP) Healthcare Licensing & Surveys Aging Division, WY Dept Health russ.forney@health.wyo.gov 307-777-7123 “Preferred” Contact: Patricia (Pat) Prince, RN pat.prince@wyo.gov 307-777-7123

  26. Questions?

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