Laying a “SAFE” Foundation

1. Laying a “SAFE” Foundation Julie Apold Mickey Reid Minnesota Hospital Association

2. 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

3. 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

4. Patient Safety Roadmaps

5. MHA Statewide Calls-to-Action

6. 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

7. SAFE from HAI Roadmap

8. Roadmap Structure • SAFE • Building Blocks • Infection-specific Gap Analyses

9. “SAFE”

10. 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

11. 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!

12. 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

13. SAFE = A (Access to Information) • Action 1: Track progress on process and outcome measures • Observational audits • Inter-rater reliability • Capture infection event details

14. 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

15. 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

16. 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

17. SAFE = F (Facility Expectations) • Action 2: Education for HCP and prescribers • Orientation  • Annually

18. 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

19. 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

20. 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”

21. Building Blocks – Hand Hygiene

22. Building Blocks – Transmission Precautions

23. Building Blocks – Antimicrobial Stewardship

24. Building Blocks – Injection Practices

25. Building Blocks – Environmental Cleaning

26. Topic Specific Gap Analyses

27. Topic Specific Gap Analyses

28. Topic Specific Gap Analyses

29. Topic Specific Gap Analyses

30. Topic Specific Gap Analyses

31. 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

32. Thresholds

33. 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

34. 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

35. 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

36. Roadmap Data Submission

37. Roadmap Data Submission

38. Roadmap Data Submission

39. Roadmap Data Submission

40. Roadmap Data Submission

41. New Hospital Reports – Action Plan

42. New Hospital Reports: Progress Report

43. New Hospital Reports: Section Report

44. New Hospital Reports: Gap Analysis

45. 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

46. 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

47. Questions?