Example Factors Characteristics That Increase Risk Characteristics that Decrease Risk Services Provided: State of Washington has cut beds Critical Care Access hospital Medical and funding for mental health centrally located in Coupeville. Surgical services, resulting in boarding ITA Hospitalist program. 4 general Emergency patients in the ED or hospital. surgeons, 3 orthopedic surgeons. Obstetrics Limited psychiatric outpatient care ED, OB, Peds care. Accredited sleep Pediatrics on the island. center. 2 rural health clinics, 2 Sleep Studies family practice clinics, 1 general Outpatient (Surgery, Lab, DI) surgery clinic, 1 orthopedic clinic and 1 women’s health clinic owned by the hospital. Hospital owns home health and hospice as well as the EMS system. DI contains state of the art CT, MRI including breast MRI and stereotactic biopsy services. Ambulatory infusion clinic staff with oncologists from Providence Hospital on the mainland provides chemotherapy services. 20
Sources of Information for the Geographic and Population Assessment • BRFSS: Behavioral Risk Factor Surveillance System (CDC) – WY coordinator : Joseph Grandpre, PhD, MPH Wyoming Department of Health Preventive Health and Safety Division 6101 Yellowstone Road, Suite 510 Cheyenne, Wyoming 82002 • CDC STD Report • Healthy Youth Survey (WA) • YRBSS: Youth Risk Behavior Risk Surveillance System – Youth online to access WY results Healthy People 2020 • http://healthypeople.gov/2020/topicsobjectives2020/pdfs/HP2020objecti ves.pdf • US Dept of Commerce, Census Bureau • US Dept of Labor, Bureau of Labor Statistics • WA CD Report: Washington State Communicable Disease Report 21
Infection Control.Prevention Risk Assessment (the excel handout) Potential Risks/ Probability Problems Risk/Impact (Health, Financial, Legal, Regulatory) Current Systems/Preparedness Score Serious Prolonged Moderate Minimum None Poor Fair Good Solid Catastrophic Loss Length of Clinical/ Clinical/ Loss (Function/ Stay Financial Financial (Life/Limb/ Financial/L Expect Function/ egal) It Likely Maybe Rare Never Financial) 4 3 2 1 0 5 4 3 2 1 5 4 3 2 1 ABX resistant organisms MRSA C Diff VRE ESBL/ other Gram Negative bacteria Failure of Prevention Activities Lack of Hand Hygiene Lack of Respiratory Hygiene/Cough Etiquette Lack of Patient Influenza Immunization Lack of Patient Pneumovax Immunization Isolation Activities 22
Tour of the Risk Assessment Grid Potential Risks/ Probability Problems Risk/Impact (Health, Financial, Legal, Regulatory) Current Systems/Preparedness Score Serious Prolonged Moderate Minimum None Poor Fair Good Solid Catastrophic Loss Length of Clinical/ Clinical/ Loss (Function/ Stay Financial Financial (Life/Limb/ Financial/L Expect Function/ egal) It Likely Maybe Rare Never Financial) 4 3 2 1 0 5 4 3 2 1 5 4 3 2 1 ABX resistant organisms MRSA C Diff VRE ESBL/ other Gram Negative bacteria Failure of Prevention Activities Lack of Hand Hygiene Lack of Respiratory Hygiene/Cough Etiquette Lack of Patient Influenza Immunization Lack of Patient Pneumovax Immunization Isolation Activities 23
Sources of Information for the Grid • Your historical data • Reports in the literature • APIC list serve • Local meetings/peer groups • Multidisciplinary team members 24
Conducting the Risk Assessment • Multidisciplinary team – Employee health, environmental services, lab, pharmacy, nursing, administration etc. • Perform at least annually – Remember to update if new services are added • Review in infection control committee • Organization determines scoring value below which no action plan is needed • Organization/committee consensus for priorities 25
Purpose of Risk Assessment Grid • Rank ordering risks by total score helps identify priorities • Priorities are built into the infection prevention and control program plan • Stratify infection risks • Review prevention and control program plan with actual data for success or needed changes to the plan 26
Let’s get started Potential Risks/ Problems Probability Risk/Impact (Health, Financial, Legal, Regulatory) Current Systems/Preparedness Score Serious Prolonged Moderate Minimum None Poor Fair Good Solid Loss Length of Clinical/ Clinical/ (Function/ Stay Financial Financial Financial/L egal) Catastrophic Loss (Life/Limb/ Expect Function/ It Likely Maybe Rare Never Financial) 4 3 2 1 0 5 4 3 2 1 5 4 3 2 1 ABX resistant organisms MRSA C Diff VRE ESBL/ other Gram Negative bacteria CRE 27
Failure of Prevention Activities Potential Risks/ Probability Problems Risk/Impact (Health, Financial, Legal, Regulatory) Current Systems/Preparedness Score Serious Prolonged Moderate Minimum None Poor Fair Good Solid Catastrophic Loss Length of Clinical/ Clinical/ Loss (Function/ Stay Financial Financial (Life/Limb/ Financial/L Expect Function/ egal) It Likely Maybe Rare Never Financial) 4 3 2 1 0 5 4 3 2 1 5 4 3 2 1 Failure of Prevention Activities Lack of Hand Hygiene Lack of Respiratory Hygiene/Cough Etiquette Lack of Patient Influenza Immunization Lack of Patient Pneumovax Immunization Antibiotic stewardship Patient placement/cohorting 28
Isolation Activities Potential Risks/ Probability Problems Risk/Impact (Health, Financial, Legal, Regulatory) Current Systems/Preparedness Score Serious Prolonged Moderate Minimum None Poor Fair Good Solid Catastrophic Loss Length of Clinical/ Clinical/ Loss (Function/ Stay Financial Financial (Life/Limb/ Financial/L Expect Function/ egal) It Likely Maybe Rare Never Financial) 4 3 2 1 0 5 4 3 2 1 5 4 3 2 1 Isolation Activities Lack of Standard Precautions Lack of Airborne Precautions Lack of Droplets Precautions Lack of Contact Precautions 29
Policy and Procedures Potential Risks/ Problems Curren Risk/Impact t Probabil (Health, Syste ity Financial, ms/Pr Legal, epare Regulatory) dness Score Serious Prolonged Moderate Minimum None Poor Fair Good Solid Catastrophic Loss Length of Clinical/ Clinical/ Loss (Function/ Stay Financial Financial (Life/Limb/ Financial/L Expect Function/ egal) It Likely Maybe Rare Never Financial) Lack of current policies or procedures (specify) Failure to follow established policy or procedure (specify) 30
Healthcare Acquired Infections Curren Potential Risks/ Problems Risk/Impact t Probabil (Health, Syste ity Financial, ms/Pr Legal, epare Regulatory) dness Score Catastrophic Serious Prolonged Moderate Minimum None Poor Fair Good Solid Loss Loss Length of Clinical/ Clinical/ (Life/Limb/ (Function/ Stay Financial Financial Expect Function/ Financial/L It Likely Maybe Rare Never Financial) egal) Healthcare Acquired Infections Surgical Site Infections (SSI) Cardiac SSI - Orthopedic Joint Replacement SSI - C-Section SSI - Other SSI - Other VAP in ICUs CLR-BSI in ICUs CLR-BSI - House wide Dialysis-Related Infections Fungal Pneumonia Norovirus CA-UTI Outbreak Sentinel Event Other - HAI 31 Other - HAI
Employee Health and “Other” Potential Risks/ Problems Curren Risk/Impact t Probabil (Health, Syste ity Financial, ms/Pr Legal, epare Regulatory) dness Score Serious Prolonged Moderate Minimum None Poor Fair Good Solid Catastrophic Loss Length of Clinical/ Clinical/ Loss (Function/ Stay Financial Financial (Life/Limb/ Financial/L Expect Function/ egal) It Likely Maybe Rare Never Financial) 4 3 2 1 0 5 4 3 2 1 5 4 3 2 1 Lack of Staff Influenza Immunization Other Risk of Community Outbreak 32
Setting Priorities 33
Rank order of the Scores Item Probability Risk/Impact Current SCORE Systems MRSA 4 4 3 48 Community 4 3 3 36 outbreak, pertussis C diff 4 4 2 32 Fail to follow 2 4 2 16 policies Lack of staff 2 4 2 16 influenza vaccination Lack of hand 2 3 2 12 hygiene 34
Rank order of scores continued Item Probability Risk/Impact Current SCORE Systems Contact 2 5 1 10 precautions SSI in a total 1 4 2 8 joint Standard 2 2 2 8 precautions Policies & 1 4 1 4 procedures 35
See handout titled “Whidbey General Hospital Infection Control & Prevention Progress Report” Priority # Priority Goal Objective Strategies Progress/ Evaluation Analysis 36
Goals and Objectives Goal Objective Something that one's efforts The purpose toward which an endeavor is or actions are intended to Meaning directed. attain or accomplish; purpose; target. I want to achieve success in the field of I want to complete this Example genetic research and do what no one has thesis on genetic research ever done. by the end of this month. Specific action - the Generic action, or better still, an outcome objective supports Action towards which we strive. attainment of the associated goal. Goals may not be strictly measurable or Must be measurable and Measure tangible. tangible. Time frame Longer term Mid to short term 37
Objectives, Strategies and Tactics • Strategies are action plans to achieve the objective • Strategies are the HOW • Tactics are specific action steps to deliver on a strategy • Tactics are a WHAT 38
Program Plan & Progress Report Progress/ Priority Evaluation Priority Goal Objective Strategies Analysis # MRSA (score 48) Pertussis outbreak (36) C diff (32) Fail to follow policies (16) Staff influenza vaccination (16) Lack of hand hygiene Contact precautions (10) SSI in a total joint (8) Standard precautions (8) Policies & procedures (4) 39
Program Plan & Progress Report Progress/ Priority Evaluation Priority Goal Objective Strategies Analysis # 1 MRSA (score 48) Pertussis outbreak (36) 2 C diff (32) 3 Fail to follow policies (16) Staff influenza vaccination (16) Lack of hand hygiene Contact precautions (10) SSI in a total joint (8) 4 Standard precautions (8) Policies & procedures (4) 40
MRSA (score 48) Goal Objective Strategies Prevent the Conduct a MRSA Risk assessment will include: transmissio risk assessment 1.Proportion of S. aureus isolates resistant to n of MRSA by___ methicillin 2. MRSA colonization incidence 3. MRSA infection incidence such as bacteremia 4. Point prevalence survey of MRSA colonization or infection Implement MRSA 1. Test adult (ICU) patients within 24 hours of monitoring admission, unless the person has already been program by ____ tested during that stay or has a known history of MRSA (WA state law) 2. Track pts + for MRSA for isolation on subsequent visits 3. Daily review of lab results 4. Regular reporting of MRSA rates to stakeholders including Sr Leadership & Board 5. External reporting to WA DOH 41
MRSA Goal Objective Strategies Prevent the Institute 1. Test and decolonize prospective total joint transmissio Prevention surgical candidates n of MRSA Practices by ____ 2. Provide decolonization therapy to MRSA colonized pts in conjunction with ICU active surveillance 3. Monitor and ensure hand hygiene compliance 4. Ensure compliance with contact precautions 5. Ensure proper disinfection of shared patient equipment 6. Use dedicated pt equipment for MDRO + pts 7. Bathe ICU pts with CHG 8. Institute MRSA room assignment consent form (WA state law) 9. Written & verbal education to pt about after care & prevention of spreading (WA state law) 42
Pertussis Community Outbreak (score 36) Priority Goal Objective Strategies Pertussis Decrease Initiate active 1. Alert ED and clinics about the outbreak morbidity surveillance outbreak and for pertussis 2. Educate providers on signs & mortality & continue symptoms, DX, TX & reporting of among for at least 42 cases infants days after 3. Encourage Peds, OB, L&D to cough onset emphasize importance of keeping of last case infants <1 away from individuals with a cough illness 4. Send periodic pertussis alerts to ED and clinics 5. Cases- ABT as soon as pertussis is suspected in pt or HCW 6. Contacts- if highly suspected in a pt, chemoprophylaxis for all close contacts & high risk contacts 43
Pertussis Community Outbreak Priority Goal Objective Strategies Pertussis Decrease Initiate active 1. OB clinic- improve rates of TDAP outbreak morbidity prevention vaccination among pregnant and program by _ women mortality 2. Monitor compliance with among respiratory/cough etiquette. infants 3. Droplet precautions in ED and inpatient 4. Screen visitors for S&S 5. Educate visitors on PPE 6. Ensure adequate PPE supplies on isolation cart 44
C diff (score 32) Priority Goal Objective Strategies C diff Reduce Assess 1. Monthly surveillance for hospital wide C the rate of implementation diff rates C diff of practices 2. Testing for toxins A & B hospitaliza that potentially 3. Immediate notification to unit by lab tions 30%. reduce C diff with + results Current 4. Use of contact precautions data is 5. Adherence to soap & water hand 13.6 washing hospitaliza 6. Environmental cleaning with tions per hypochlorite based disinfectant each 1000 occupied day discharges. 7. Terminal clean with hypochlorite based disinfectant on discharge 8. Dedicated pt equipment 9. Use of EPA approved disinfectant to clean common equipment like wheelchairs 45
C diff Priority Goal Objective Strategies C diff Reduce Assess 11. Policy/protocol for treatment of C diff the rate of implementation 12. Antibiotic stewardship in treatment of C diff of practices CDI hospitaliza that potentially 13. Flag placed in EMR tions 30%. reduce C diff 14. ATP/glow germ to test room cleanliness Current quarterly with Environmental Services and data is IP 13.6 15. Monthly unit dashboards containing hospitaliza infection data disseminated to front line tions per staff and leadership 1000 16. Best practice certificates given to units discharges. that are high performers 17. Pt and family/caregiver education 46
SSI in a total joint (score 8) Goal Objective Strategies Zero SSI Reduce 1. Continue focused surveillance for SSI in total incidence and 2. Revise post discharge surveillance to include post hip and consequences of discharge call to pt asking specific questions r/t knee SSI in total joint signs of infection arthropl from ___ to ___ 3. Report SSI data to Chief of Surgery, OR asty by___ Governance, Quality Com, Sr Leadership, surgeons. 4. Assess current process & reliability of each best practice to determine areas in most need of improvement. (goal is 95% or >) 5. Monitor SCIP measures for 100% compliance 6. 3 days prior to surgery, instruct pt to bathe with CHG daily 7. Screen pts for Staph aureus & decolonize SA carriers with 5 days of intranasal mupirocin 8. OR rounds and IP monitoring of skin prep 47
You Can’t Do It All At Once! And you can’t do it alone… • Set quarterly priorities • Note what has been assigned and/or delegated to others • Update your plan in the Infection Prevention Committee meeting – Progress – Challenges – Barriers 48
Re-visiting the Plan Goal Objective Strategies Prevent the Conduct a MRSA Risk assessment will include: transmissio risk assessment 1.Proportion of S. aureus isolates resistant to n of MRSA by Quarter 1, methicillin 2014. Infection 2. MRSA colonization incidence Preventionist. 3. MRSA infection incidence such as bacteremia 4. Point prevalence survey of MRSA colonization or infection Implement MRSA 1. Test adult (ICU) patients within 24 hours of monitoring admission, unless the person has already been program by tested during that stay or has a known history Quarter 1, 2014. of MRSA (WA state law) Infection 2. Track pts + for MRSA for isolation on Preventionist. subsequent visits 3. Daily review of lab results 4. Regular reporting of MRSA rates to stakeholders including Sr Leadership & Board 5. External reporting to WA DOH 49
Goal Objective Strategies Prevent the Institute 1. Test and decolonize prospective total joint surgical transmission candidates. Pre-op assessment RN with Ortho Prevention of MRSA 2. Provide decolonization therapy to MRSA colonized pts Practices by in conjunction with ICU active surveillance. Ortho Quarter 2, 2014 Clinic 3. Monitor and ensure hand hygiene compliance Hand Hygiene Team 4. Ensure compliance with contact precautions IP, Nsg. Daily rounding. 5. Ensure proper disinfection of shared patient equipment. Nsg 6. Use dedicated pt equipment for MDRO + pts Nsg 7. Bathe ICU pts with CHG Nsg 8. Institute MRSA room assignment consent form (WA state law) Pt Access, IP 9. Written & verbal education to pt about after care & prevention of spreading (WA state law). IP develops, Nsg Provides 50
Priority Goal Objective Strategies Pertussis Decrease Initiate active 1. Alert ED and clinics about the outbreak morbidity surveillance outbreak. IP and for pertussis 2. Educate providers on signs & mortality & continue symptoms, DX, TX & reporting of among for at least 42 cases. IP, ED Med Director, Chief of infants days after Staff cough onset 3. Encourage Peds, OB, L&D to of last case. emphasize importance of keeping NOW! infants <1 away from individuals with a cough illness. IP, Chief of Medicine 4. Send periodic pertussis alerts to ED and clinics IP 5. Cases- ABT as soon as pertussis is suspected in pt or HCW. Providers 6. Contacts- if highly suspected in a pt, chemoprophylaxis for all close contacts & high risk contacts. Providers, Occ Health 51
Priority Goal Objective Strategies Pertussis Decrease Initiate active 1. OB clinic- improve rates of TDAP outbreak morbidity prevention vaccination among pregnant and program by women OB Providers mortality NOW! 2. Monitor compliance with among respiratory/cough etiquette. infants Nursing Practice Council 3. Droplet precautions in ED and inpatient Nursing 4. Screen visitors for S&S Volunteers & Pt Access 5. Educate visitors on PPE PR 6. Ensure adequate PPE supplies on isolation cart Central Supply 52
Priority Goal Objective Strategies C diff Reduce Assess 1. Monthly surveillance for hospital wide C the rate of implementation diff rates IP C diff of practices 2. Testing for toxins A & B Lab hospitaliza that potentially 3. Immediate notification to unit by lab tions 30%. reduce C diff with + results Lab Current By Quarter 1, 4. Use of contact precautions Nsg, IP daily data is 2014 rounds 13.6 5. Adherence to soap & water hand hospitaliza washing Hand Hygiene Team, IP tions per 6. Environmental cleaning with 1000 hypochlorite based disinfectant each discharges occupied day IP informs Env Services By Jan 1, 7. Terminal clean with hypochlorite based 2015 disinfectant on discharge Env Services 8. Dedicated pt equipment Nsg 9. Use of EPA approved disinfectant to clean common equipment like wheelchairs Env Services 53
Priority Goal Objective Strategies C diff Reduce the Assess 11. Policy/protocol for treatment of C diff rate of C diff implementati IP, Chief of Medicine hospitalizati on of 12. Antibiotic stewardship in treatment of ons 30%. practices that CDI QR Med Director, Pharm Director, Lab Current data potentially Mgr, MEC is 13.6 reduce C diff 13. Flag placed in EMR IP hospitalizati By Quarter 1, 14. ATP/glow germ to test room cleanliness ons per 2014 quarterly with Environmental Services and 1000 IP Env Svs & IP discharges. 15. Monthly unit dashboards containing By Jan 1, infection data disseminated to front line 2015 staff and leadership IP w/ QR 16. Best practice certificates given to units that are high performers IP 17. Pt and family/caregiver education IP develops, Nsg provides 54
Goal Objective Strategies Zero SSI in Reduce 1. Continue focused surveillance for SSI IP total hip incidence and 2. Revise post discharge surveillance to include post and knee consequences discharge call to pt asking specific questions r/t arthroplasty of SSI in total signs of infection IP, maybe Care Mgt calls the pt joint from ___ 3. Report SSI data to Chief of Surgery, OR Governance, to ___ by Quality Com, Sr Leadership, surgeons IP Quarter 4, 2014 4. Assess current process & reliability of each best practice to determine areas in most need of improvement. (goal is 95% or >) IP 5. Monitor SCIP measures for 100% compliance QR w/IP 6. 3 days prior to surgery, instruct pt to bathe with CHG daily Pre-op Nurse 7. Screen pts for Staph aureus & decolonize SA carriers with 5 days of intranasal mupirocin Ortho Clinic 8. OR rounds and IP monitoring of skin prep IP, OR Mgr monthly 55
Keeping It Realistic, Q 1 for IP 1. Alert ED and clinics about the Pertussis outbreak. IP 2. Educate providers on Pertussis signs & symptoms, DX, TX & reporting of cases. IP, ED Med Director, Chief of Staff 3. Encourage Peds, OB, L&D to emphasize importance of keeping infants <1 away from individuals with a cough illness. IP, Chief of Medicine 4. Send periodic Pertussis alerts to ED and clinics IP 5. Conduct MRSA risk assessment IP 6. Implement MRSA monitoring program IP 7. Daily rounding to ensure compliance with contact precautions IP, Nsg 8. Monthly surveillance for hospital wide C diff rates IP 9. Adherence to soap & water hand washing Hand Hygiene Team, IP 10. Policy/protocol for treatment of C diff IP, Chief of Medicine 11. C diff Flag placed in EMR IP 12. ATP/glow germ to test room cleanliness quarterly Env Svs & IP 13. Monthly unit dashboards containing infection data disseminated to front line staff and leadership IP w/ QR 14. Best practice certificates given to units that are high performers IP 15. Pt and family/caregiver education IP develops, Nsg provides 56
Keeping It Realistic, Q 2 for IP 1. Institute MRSA room assignment consent form (WA state law) Pt Access, IP 2. Written & verbal education to pt about after care & prevention of spreading (WA state law). IP develops in Q2, Nsg Provides 3. Continue focused surveillance for SSI IP 4. Revise post discharge surveillance to include post discharge call to pt asking specific questions r/t signs of infection IP in Q2, maybe Care Mgt calls the pt starting Q3 5. Report SSI data to Chief of Surgery, OR Governance, Quality Com, Sr Leadership, surgeons IP 6. Assess current process & reliability of each best practice to determine areas in most need of improvement. (goal is 95% or >) IP 7. Monitor SCIP measures for 100% compliance QR w/IP 8. OR rounds and IP monitoring of skin prep IP, OR Mgr monthly 57
Working Through Others supported by the CMS Worksheet & Regs • 1. B.1 The Infection Control Officer(s) can provide evidence that problems identified in the infection control program are addressed in the hospital QAPI program (i.e., development and implementation of corrective interventions, and ongoing evaluation of interventions implemented for both success and sustainability). • 1. B.3 Hospital leadership, including the CEO, Medical Staff, and the Director of Nursing Services ensures the hospital implements successful corrective action plans in affected problem area(s). 58
Working Through Others supported by APIC’s Competency Model • “IP’s leadership is based on influence rather than authority, and this influence is a consequence of skills in the 5 content categories – Collaboration – Followership – Program Management – Critical thinking skills – Communication Murphy, D. et al. AJIC 40 (2102) 296-303 59
Moving to the Progress/Analysis Section Priority Priority Goal Objective Strategies Progress/ Evaluation # Analysis 48 MRSA Prevent the Conduct a MRSA Risk assessment will include: transmission risk assessment 1.Proportion of S. aureus of MRSA by Quarter 1, isolates resistant to 2014. Infection methicillin Preventionist. 2. MRSA colonization incidence 3. MRSA infection incidence such as bacteremia 4. Point prevalence survey of MRSA colonization or infection 36 Pertussis Decrease Initiate active 1. OB clinic- improve rates outbreak morbidity and prevention of TDAP vaccination mortality program by among pregnant among NOW! women OB Providers infants 2. Monitor compliance with respiratory/cough etiquette. Nursing Practice Council 3. Droplet precautions in ED and inpatient Nursing 60
Progress/Analysis Priority Strategy Progress/Analysis MRSA Risk assessment will include: Q1: Assessment completed 3/2014. 1.Proportion of S. aureus isolates 50% of S. aureus isolates are methicillin resistant to methicillin resistant. 2. MRSA colonization incidence No MRSA HAI this quarter. 3. MRSA infection incidence such as Point prevalence results, 15% of adult bacteremia admissions on 2/24/14 were MRSA +, of 4. Point prevalence survey of MRSA which 98% were previously known and colonization or infection were already in contact isolation. Share results with Nsg to stress importance of standard precautions and hand hygiene. 1. Test adult (ICU) patients within 24 Q1: State mandated MRSA ICU testing and hours of admission, unless the person reporting in place. has already been tested during that See attached chart for MRSA rates. stay or has a known history of MRSA (WA state law) 2. Track pts + for MRSA for isolation on subsequent visits 3. Daily review of lab results 4. Regular reporting of MRSA rates to stakeholders including Sr Leadership & Board 5. External reporting to WA DOH 61
Date Pts tested Pts Positive Percent Positive Jan 3 1 33 Feb 2 0 0 March 4 1 25 April 1 0 0 ICU Patients, Percent MRSA Positive on Admission 2014 35 30 25 20 15 Percent Positive 10 5 0 Jan Feb March April 62
Priority Strategy Progress/Analysis C. diff 1. Monthly surveillance for Q1: Surveillance in process. See hospital wide C diff rates IP attached chart. 2. Testing for toxins A & B Lab Lab alert written & populates nurse’s 3. Immediate notification to work list. unit by lab with + results Lab IP daily rounds in March showed 4. Use of contact precautions decrease in compliance with signs Nsg, IP daily rounds & 3 pts were not isolated. 1:1 5. Adherence to soap & water education provided. hand washing Hand Hygiene Bed board rule written to alert Env Svs Team, IP of C. diff rooms for bleach 6. Environmental cleaning with cleaning. hypochlorite based disinfectant each occupied day IP informs Env Services 63
Priority Strategy Progress/Analysis SSI, 1. Continue focused surveillance for SSI Q1 increase in superficial incisional infections in IP total knees. All of the infections were a total 2. Revise post discharge surveillance to locum surgeon’s. See chart. ABT timing joints include post discharge call to pt ranging from 85-95% compliance due to lack asking specific questions r/t signs of of on time delivery from pharmacy. ABT infection IP, maybe Care Mgt calls the ordering & delivery process reviewed with pt Pharm. Post discharge surveillance call sheet 3. Report SSI data to Chief of Surgery, developed. OR Governance, Quality Com, Sr Leadership, surgeons IP 4. Assess current process & reliability of each best practice to determine areas in most need of improvement. (goal is 95% or >) IP 5. Monitor SCIP measures for 100% compliance QR w/IP 6. 3 days prior to surgery, instruct pt to bathe with CHG daily Pre-op Nurse 7. Screen pts for Staph aureus & decolonize SA carriers with 5 days of intranasal mupirocin Ortho Clinic 8. OR rounds and IP monitoring of skin prep IP, OR Mgr monthly 64
Percent Superficial Infections, Total Knee 2013- 2014 Jan Feb Mar Apr May Jun Jul Aug Spe Oct Nov Dec Jan Feb Mar 10 9 8 Locum 7 Surgeon 6 Percent Superficial 5 4 3 2 1 0 65
Priority Strategy Progress/Analysis SSI, 1. Continue focused surveillance for SSI Q1 increase in superficial incisional infections in IP total knees. All of the infections were a total 2. Revise post discharge surveillance to locum surgeon’s. See chart. ABT timing joints include post discharge call to pt ranging from 85-95% compliance due to lack asking specific questions r/t signs of of on time delivery from pharmacy. ABT infection IP, maybe Care Mgt calls the ordering & delivery process reviewed with pt Pharm. Post discharge surveillance call sheet 3. Report SSI data to Chief of Surgery, developed. OR Governance, Quality Com, Sr Q2 No superficial incisional infections in total Leadership, surgeons IP knees. Zero deep infections for hips and 4. Assess current process & reliability of knees continues. SCIP measures at 100%. OR each best practice to determine areas rounds noted lack of proper OR attire ( masks in most need of improvement. (goal is below the nose, hair not contained). 95% or >) IP Education in OR staff mtg. 5. Monitor SCIP measures for 100% Q3 Care management implemented post compliance QR w/IP discharge surveillance tool. 75 calls 6. 3 days prior to surgery, instruct pt to completed /145 surgical patients (52%). Q4 bathe with CHG daily Pre-op Nurse goal set at 75%. 7. Screen pts for Staph aureus & Q4 New orthopedic surgeon hired. SCIP decolonize SA carriers with 5 days of composite score dropped from 100% to 95%. intranasal mupirocin Ortho Clinic Chief of Surgery addressed in OR 8. OR rounds and IP monitoring of skin Governance. Individual non-compliance will prep IP, OR Mgr monthly be sent to peer review. 66
Evaluation 67
Moving to the Evaluation Section Priority Priority Goal Objective Strategies Progress/ Evaluation # Analysis 48 MRSA Prevent the Conduct a MRSA Risk assessment will include: transmission risk assessment 1.Proportion of S. aureus of MRSA by Quarter 1, isolates resistant to 2014. Infection methicillin Preventionist. 2. MRSA colonization incidence 3. MRSA infection incidence such as bacteremia 4. Point prevalence survey of MRSA colonization or infection 36 Pertussis Decrease Initiate active 1. OB clinic- improve rates outbreak morbidity and prevention of TDAP vaccination mortality program by among pregnant among NOW! women OB Providers infants 2. Monitor compliance with respiratory/cough etiquette. Nursing Practice Council 3. Droplet precautions in ED and inpatient Nursing 68
Priority Strategy Progress/Analysis C. diff 1. Monthly surveillance for Q1 : Surveillance in process. See attached hospital wide C diff rates IP chart. Lab alert written & populates nurse’s work 2. Testing for toxins A & B Lab list. 3. Immediate notification to IP daily rounds in March showed decrease unit by lab with + results Lab in compliance with signs & 3 pts were 4. Use of contact precautions not isolated (compliance at 80%). 1:1 Nsg, IP daily rounds education provided. 5. Adherence to soap & water Bed board rule written to alert Env Svs of C. hand washing Hand Hygiene diff rooms for bleach cleaning. Team, IP Q2 Compliance with contact precautions remains inconsistent. Staff observed 6. Environmental cleaning with not gowning & gloving to enter room. hypochlorite based Nsg states they don’t have time to disinfectant each occupied restock the carts. day IP informs Env Services Q3 Env Serv stocking carts. Contact precautions compliance improved to 95%. 2 pts were not isolated, lab did not alert IP or Nsg of + test. Q4 ABT Stewardship CME given. C diff rate 13/10,000 pt days. 69
Evaluation Progress/Analysis Evaluation Q1: Surveillance in process. See attached chart. Q1 Contact precaution daily Lab alert written & populates nurse’s work list. surveillance during IP rounds IP daily rounds in March showed decrease in continues. compliance with signs & 3 pts were not Q2 PIP team launched to address isolated (compliance at 80%). 1:1 education provided. stocking isolation carts. Bed board rule written to alert Env Svs of C. diff Q3 Contact precaution compliance rooms for bleach cleaning. improving with Env Svs stocking carts. Q2 Compliance with contact precautions remains inconsistent. Staff observed not gowning & Glitch in lab module resulted in alerts gloving to enter room. Nsg states they don’t not being sent to nurses’ work lists. Lab have time to restock the carts. changed parameters and did not use Q3 Env Serv stocking carts. Contact precautions change control process. Correction compliance improved to 95%. 2 pts were not isolated, lab did not alert IP or Nsg of + test. now complete. Q4 ABT Stewardship CME given. C diff rate Q4 C diff rate remains high, 13,10,000 13/10,000 pt days. pt days. ABT stewardship CME given. Chief of Medicine agreed to charter PIP addressing unnecessary ABT. 70
QAPI 71
72
High Reliability in Healthcare • Method to ensure pt safety and quality of care – Based on system design – Technical skills and Non-technical skills • Defined as defect free operations for long periods of time • High reliability organizations implement specific training to minimize errors 73
Model for High Reliability Teams Culture of Safety High Reliability = Technical skills + non-technical skills + process design Technical skills Non-Technical skills Training Cognitive Competence Interpersonal competencies Commitment to Monitoring team education and performance certification Knowledge of team roles Positive attitude 74
High Reliability Teams Culture of Safety High Reliability = Technical skills + non-technical skills + process design Failure of team work Failure of communication Failure of process design 75
High Performing Teams • Behavioral markers – Establishing leadership – Situational awareness – Closed loop communication – Shared mental model 76
Organizational Learning • Successful organizations – Define learning agenda based on their knowledge gaps – Open to discordant information – Reports are trusted because relationships and reporting systems are healthy – Avoid repeated mistakes • Reflect on experience, distill lessons, share the knowledge and refine the process – Knowledge is common property 77
To Learn • One must be humble. No one person knows it all • Learning demands openness • Everyone needs to be willing to challenge assumptions – Think more deeply • Leaders create supportive learning environment – Move from “this is the way we have always done it” – Accept occasional failures and mistakes as the price of improvement • Pressure alone does not produce creative and innovative thinking or solutions 78
Safe Culture/Just Culture • Encourage staff to reveal/report mistakes • Near misses are our free lessons – Reveal potential dangers – Warning signals to exposure of vulnerability – Take time to learn from them • Celebrate the good catch • Fix the system/process issues instead of a fixing blame – Freedom to fail should not be confused with a license to commit foolish mistakes 79
No “Simple” Explanations • High reliability organizations are reluctant to accept the simple explanation for problems • Some simple explanations – Poor communication – Staffing shortages – Limited resources • Dig deeper, the explanation may be under the superficial one 80
Percent Superficial Infections, Total Knee 2013- 2014 Jan Feb Mar Apr May Jun Jul Aug Spe Oct Nov Dec Jan Feb Mar 10 9 Locum 8 Surgeon 7 6 Percent Superficial 5 4 3 2 1 No orientation to our processes 0 He hurried the OR staff= inadequate skin prep ABT not on time Doesn’t believe in pre-op antiseptic showering 81
Quality Focused Culture • Culture is a consensus view of the way we do things • Leverages the knowledge, skills and expertise of healthcare workers – To develop methods and strategies to improve healthcare and patient safety • Employs multidisciplinary teams – Increased creativity for problem solving – Increased acceptance of solutions – Improved productivity – Positive impact on morale – Helps align work with organization mission, vision and values 82
Tools for Performance Improvement • Gap analysis • Goal directed checklists • Fishbone “Ishikawa” • Resources for a variety of tools – www.asq.org • Seven basic quality tools • Project planning tools • Go to knowledge center and click on tools tab 83
Gap Analysis • Helps to move from current state to desired state • Identifies gaps that exist between current processes and new standard • Team takes steps to fill the gaps 84
Gap Analysis Tool Future State Current Situation Next Actions Foley catheters will be 90% of Foley catheters are discontinued with in post op discontinued after 54 hours day 1 or 2 with day of surgery post op. being day zero 85
Quality Tools Resources • AHRQ Quality Indicators Toolkit – AHRQ Tool Kit for Hospitals • Outlines steps for improvement with toolkit roadmap – Gap Analysis Tool (Tool D.5) – Implementation Plan (Tool D.6) – www.ahrq.gov/qual/’qitoolkit/qitoolkit.pdf 86
Gap Analysis Tool Project: Best Practice: Individual completing form: Best Practice Best Practice How your Barriers t o Implement Strategies practice best practice best differs from implementati practice? best practice on Y/N? Why not? From AHRQ Quality Indicator Tool Kit 87
Implementation Plan Project: Individual completing this form: Detailed Team Target Actual Communication/ Communication/ Communication/ Best Go Live Project Training Training Training Tasks/Action member completion completion Date completed? Practice required? schedule date completion date associated with assigned date date Y/N from Y/N implementation to each Gap task Analysis 88
Goal Directed Checklists • Follows aviation model • Helps with memory recall • Makes explicit the steps to complete complex procedures • Incorporates evidence based quality parameters • Bundles- VAP, Sepsis, Central line insertion, Bladder 89
Checklist Resources • Atul Gawande: Checklist Manifesto: How to get Things Right • Peter Pronovost: Safe Patients, Smart Hospitals • AHRQ Central Line Insertion Care Team Checklist at www.ahrq.gov/qual/clichklist.htm • Safer ICUs Eliminating CLABSI Collaborative Project Management Task list at www.ncqualitycenter.org 90
Outcome & Process Measures 91
Outcome Measures • These measures tell you whether changes are actually leading to improvement • Examples of outcome measures: – Adverse Drug Events (ADEs) per 1,000 Doses – Number of Cases between Surgical Site Infections. 92
What are process measures? • To affect the outcome measure of improving patient safety, you will make changes to improve many core processes • Measuring the results of these process changes will tell you if the changes are leading to an improved, safer system • Examples include: – Percentage of Staff Reporting a Positive Safety Climate – Pharmacy Interventions per 100 Admissions – Percent of Surgical Cases with On-Time Prophylactic Antibiotic Administration – Compliance with a bundle 93
We need both measures • Outcome and process measures need to be balanced – to make sure that changes to improve one part of the system aren’t causing new problems in other parts of the system • Example: – Glucose protocol, monitor compliance with new order set (process) and hypo/hyperglycemic events (outcomes) 94
Measures Process Measure • Outcome Measure • – Foley catheter d/c within 24 – CAUTI rate in surgical patients hours of surgery – Percent compliance with central – CLABSI rate line insertion checklist 95
Customer & Stakeholder Customer driven input strategic Performance reporting to Management planning customers/stakeholders Priorities/Decisions Goal setting Resource planning Evaluate and Annual utilize performance performance planning information Resource allocation Analyze and review data Data collection and reporting Establish accountability Performance measurement goals 96
Performance Improvement 97
Performance Improvement Methodologies: PDSA or PDCA • Plan, Do, Study, Act • Plan – Identify goals, available resources and actions or steps to take • Do – Implement the activities or steps identified • Study or Check – Analyze data, benchmark, trend data • Act – Based on analysis redefine actions or steps to take to achieve the goal – Continuous cycle 98
Six Sigma • D efine a problem or improvement opportunity • M easure process performance • A nalyze the process and determine the root causes of poor performance and if the process can be improved or redesigned • I mprove the process • C ontrol the improved process to hold the gains 99
Performance Improvement Methodologies: CUSP and TRIP • CUSP – Comprehensive Unit based Safety Program • TRIP – Translating Research into Practice • CUSP and TRIP are a two pronged approach to performance improvement • Both will be discussed in more detail in the following slides 100
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