2010 sAFE pRACTICE REPORt - Southern Ohio Medical Center

Transcription

2010 SAFE PRACTICE REPORT
36-0008 Southern Ohio Medical Center
Prepared by
The Leapfrog Group
2010 LEAPFROG SAFE PRACTICE REPORT for 36-0008 SOUTHERN OHIO MEDICAL CENTER
The LHRP Safe Practice Report provides an in-depth comparison of your hospital's performance on each element of the 17 NQF Safe Practices included
on the Leapfrog Hospital Survey compared to other hospitals in our 2010 database. The report is the second in a series of LHRP reports that will give
hospitals a competitive analysis of their Leapfrog performance. The LHRP Safe Practice Report includes the following safe practices:
Safe Practice 1 Leadership Structures and Systems
Safe Practice 2 Culture Measurement for Performance
Safe Practice 3 Teamwork Training and Skill Building
Safe Practice 4 Identification and Mitigation of Risks and Hazard
Safe Practice 5 Informed Consent
Safe Practice 6 Life Sustaining Treatment
Safe Practice 9 Nursing Workforce
Safe Practice 12 Communication of Critical Information
Safe Practice 14 Labeling of Diagnostic Studies
Safe Practice 15 Discharge Systems
Safe Practice 17 Medication Reconciliation
Safe Practice 19 Hand Hygiene
Safe Practice 21 Central Venous Catheter Related Bloodstream Infection
Prevention
Safe Practice 23 Prevention of Ventilator Associated Complications
Safe Practice 25 Catheter Associated Urinary Tract Infection Prevention
Safe Practice 28 DVT/VTE Prevention
Safe Practice 29 Anticoagulation Therapy
Page 1 of 51
©2010, 2011 The Leapfrog Group
Report created on 5/2/2012
www.leapfroggroup.org
THE DATABASE
1206 hospitals provided responses to the Safe Practice Section of the 2010 Leapfrog Hospital Survey.
SAFE PRACTICE SCORING: PERFORMANCE GROUPS
The Leapfrog Safe Practices Score (SPS) measures hospitals’ progress on 17 of the National Quality Forum Safe Practice areas. Each practice area is
assigned an individual weight, which is factored into the overall score. Hospitals are then ranked by quartiles based on their relative progress out of the
total number of possible points and assigned a performance group.
• Fully meets standards means the hospital is in the highest quartile for Overall Points across all Safe Practices that apply to the hospital.
• Substantial progress means the hospital is above the midpoint (median), but not in the top quartile, for Overall Points across all Safe Practices
that apply to the hospital.
• Some progress means the hospital is below midpoint (median), but not in the lowest quartile, for Overall Points across all Safe Practices that
apply to the hospital.
• Willing to report means the hospital is in the lowest quartile for Overall Points.
Within each Safe Practice/Element, each checkbox has the same value, equal to the total points assigned to that Practice/Element divided by the
number of checkboxes in that Practice/Element. Where a hospital’s responses indicate that a Safe Practice does not apply, the total available points will
be less than the maximum 737 points. In these cases, total points earned for checked items is rebalanced (upward) by the ratio of maximum points to
total available points to put the hospital on equal footing with other hospitals to which those NA-items do apply.
% RANK
Your hospital’s percentile rank represents the proportion of scores that your hospital’s score is greater than or equal to. For instance, if you received a
score of 120 points for Safe Practice #1 and this score were greater than or equal to the scores of 72% of the hospitals that completed this safe practice
section, then your percentile rank would be 72. You would be in the 72nd percentile. If you earned the maximum number of points on a particular safe
practice, but your percentile rank seems low, it is likely due to the fact that many hospitals also earned the maximum number of points on that safe
practice.
COMPLETE DESCRIPTIONS OF NQF SAFE PRACTICES
A complete list of the NQF Safe Practices and their corresponding elements is attached. The numbers and letters referenced in this report (e.g. 1.1a)
match exactly to the numbers and letters in the attached document.
Page 2 of 51
HOSPITAL DASHBOARD
SAFE PRACTICE PERFORMANCE GROUP:
SOME PROGRESS
TOTAL POINTS
EARNED BY YOUR
HOSPITAL
TOTAL POSSIBLE
POINTS
STATE
AVERAGE
NATIONAL
AVERAGE
111.43
120
104.61
104.70
2 Culture Measurement for Performance
4.44
20
16.98
16.51
3 Teamwork Training and Skill Building
12.0
40
30.31
30.30
4 Identification and Mitigation of Risks and Hazards
108
120
103.66
102.77
5 Informed Consent
1.82
4
2.37
2.50
6 Life Sustaining Treatment
2.67
4
2.52
2.50
9 Nursing Workforce
86.36
100
83.79
85.54
12 Communication of Critical Information
84.00
84
70.76
69.74
12
15
10.95
11.80
15 Discharge Systems
15.28
25
20.10
19.38
17 Medication Reconciliation
32.67
35
30.42
30.71
19 Hand Hygiene
24.00
30
25.55
26.25
21 Central Venous Catheter Related Bloodstream Infection Prevention
30
30
24.81
27.20
23 Prevention of Ventilator Associated Complications
20
20
15.38
17.53
25 Catheter Associated Urinary Tract Infection Prevention
30
30
24.25
23.82
28 DVT/VTE Prevention
25
25
19.68
21.07
29 Anticoagulation Therapy
30
35
25.15
26.48
629.67
737
611.30
618.64
2010 NQF SAFE PRACTICE
1 Leadership Structures and Systems
14 Labeling of Diagnostic Studies
TOTAL
Page 3 of 51
SAFE PRACTICE 1 LEADERSHIP STRUCTURES AND SYSTEMS
Leadership structures and systems must be established to ensure that there is organization-wide awareness of patient safety performance gaps,
direct accountability of leaders for those gaps, and adequate investment in performance improvement abilities, and that actions are taken to
ensure safe care of every patient served.
SAFE PRACTICE 1 TOTAL POSSIBLE POINTS
Points Earned by Your Hospital
Average Points Earned by Your Performance Group
Average Points Earned by Top Performance Group
Average Points Earned by All Hospitals in the Database
Your Hospital’s % Rank
ELEMENTS OF SAFE PRACTICE 1
LEADERSHIP STRUCTURES AND SYSTEMS
1.1a
1.1b
1.1c
1.1d
1.2a
1.2b
1.2c
1.2d
1.2e
1.3a
1.3b
1.4a
1.4b
1.4c
Page 4 of 51
120
111.43
103.29
115.85
104.70
37.50
Your Hospital's
Responses
Yes or No
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Your
Performance
Group
%Yes
98.84
22.48
82.56
97.67
98.45
91.86
77.52
96.12
84.11
96.51
76.36
95.74
98.45
83.72
%No
1.16
77.52
17.44
2.33
1.55
8.14
22.48
3.88
15.89
3.49
23.64
4.26
1.55
16.28
Top
Performance
Group
%Yes
100
60
98.84
99.77
100
99.53
99.07
100
97.21
100
98.37
100
99.77
98.84
%No
0
40
1.16
.23
0
.47
.93
0
2.79
0
1.63
0
.23
1.16
All Hospitals
%Yes %No
97
3
37
63
87
13
2
98
96
4
92
8
92
8
95
5
87
13
93
7
81
19
95
5
95
5
86
14
SAFE PRACTICE 2 CULTURE, MEASUREMENT, FEEDBACK AND INTERVENTION
Healthcare organizations must measure their culture, provide feedback, to the leadership and staff, and undertake interventions that will reduce
patient safety risk.
CULTURE, MEASUREMENT, FEEDBACK AND INTERVENTION
2.1a
2.1b
2.2a
2.2b
2.3a
2.3b
2.4a
2.4b
2.4c
Page 5 of 51
20
4.44
16.05
19.3
16.51
6.30
Your Hospital's
Responses
Yes or No
Yes
No
Yes
No
No
No
No
No
No
Your
Performance
Group
%Yes
95.35
81.78
92.64
82.17
79.84
69.38
74.81
69.77
73.64
%No
4.65
18.22
7.36
17.83
20.16
30.62
25.19
30.23
26.36
Top
Performance
Group
%Yes
99.07
95.35
98.60
97.44
96.74
97.21
93.95
94.65
95.58
%No
.23
4.65
1.40
2.56
3.26
2.79
6.05
5.35
4.42
All Hospitals
%Yes %No
94
6
84
16
91
9
85
15
82
8
75
5
79
21
76
24
77
23
SAFE PRACTICE 3 TEAMWORK, TRAINING AND SKILL BUILDING
Healthcare organizations must establish a proactive, systematic, organization-wide approach to developing team-based care through teamwork
training, skill building, and team-led performance improvement interventions that reduce preventable harm to patients.
TEAMWORK, TRAINING AND SKILLS BUILDING
3.1a
3.1b
3.1c
3.1d
3.2a
3.2b
3.3a
3.3b
3.4a
3.4b
Page 6 of 51
40
12
28.39
38.8
30.30
9.20
Your Hospital's
Responses
Yes or No
Yes
No
No
No
Yes
No
Yes
No
No
No
Your
Performance
Group
%Yes
77.13
82.95
79.07
89.92
68.99
46.90
70.93
62.40
71.71
56.98
%No
22.87
17.05
20.93
10.08
31.01
53.10
29.07
37.60
28.29
43.02
Top
Performance
Group
All Hospitals
%Yes %No %Yes %No
97.21 2.79
80
20
97.67 2.33
84
16
99.30 .70
80
20
99.07 .93
90
10
98.60 1.40
74
26
89.53 10.47
59
41
99.30 .70
76
24
95.98 4.02
71
29
93.37 6.63
77
23
93.95 6.05
66
34
SAFE PRACTICE 4 IDENTIFICATION AND MITIGATION OF RISKS AND HAZARDS
Healthcare organizations must systematically identify and mitigate patient safety risks and hazards with an integrated approach in order to
continuously drive down preventable patient harm.
IDENTIFICATION AND MITIGATION OF RISKS AND HAZARDS
4.1a
4.1b
4.1c
4.1d
4.2a
4.2b
4.3a
4.3b
4.4a
4.4b
Page 7 of 51
120
108
103.38
119.55
102.77
31.30
Your Hospital's
Responses
Yes or No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Your
Performance
Group
%Yes
99.61
94.96
92.25
75.19
90.31
68.99
93.41
70.16
83.33
89.92
%No
.39
5.04
7.75
24.81
9.69
31.01
6.59
29.84
16.67
10.08
Top
Performance
Group
%Yes
100
99.77
100
99.53
99.77
98.37
100
98.84
100
100
%No
0
.23
0
.47
.23
1.63
0
1.16
0
0
All Hospitals
%Yes %No
98
2
94
6
90
10
78
22
87
13
74
26
88
12
75
25
84
16
88
12
SAFE PRACTICE 5 INFORMED CONSENT
Ask each patient or legal surrogate to “teach back,” in his or her own words, key information about the proposed treatments or procedures for which
he or she is being asked to provide informed consent.
INFORMED CONSENT
5.1a
5.1b
5.1c
5.2a
5.2b
5.2c
5.3a
5.3b
5.3c
5.4a
5.4b
Page 8 of 51
4
1.82
2.17
3.31
2.50
27.60
Your Hospital's
Responses
Yes or No
Yes
No
No
Yes
Yes
No
No
yes
Yes
Yes
No
Your
Performance
Group
%Yes
65.12
58.14
23.64
47.67
45.74
32.17
43.02
51.94
96.12
89.92
39.92
%No
34.88
41.86
76.36
52.33
54.26
67.83
59.98
48.06
3.88
10.08
60.08
Top Performance
Group
%Yes
91.16
92.56
72.33
86.60
88.37
71.63
75.35
57.91
9199.7
99.77
7
96.05
75.81
%No
8.84
7.44
27.67
13.40
11.63
28.37
24.65
5
42.09
.23
3.95
24.19
All Hospitals
%Ye
s
70
67
42
59
58
45
54
53
94
87
52
%N
o
30
33
58
41
42
55
46
47
6
13
48
SAFE PRACTICE 6 LIFE SUSTAINING TREATMENT
Ensure that written documentation of the patient’s preferences for Life-Sustaining Treatment life-sustaining treatments is prominently displayed in
his or her chart.
LIFE SUSTAINING TREATMENT
6.1a
6.1b
6.1c
6.2a
6.2b
6.2c
6.3a
6.4a
6.4b
Page 9 of 51
4
2.67
1.99
3.54
2.50
46.20
Your Hospital's
Responses
Yes or No
Yes
Yes
No
Yes
Yes
No
Yes
Yes
No
Your
Performance
Group
%Yes
77.13
56.69
21.32
42.64
33.33
20.16
63.95
85.66
42.64
%No
22.87
40.31
78.68
57.36
66.67
79.84
36.05
14.34
57.36
Top
Performance
Group
%Yes
97.67
92.56
74.65
90.23
87.44
75.81
93.26
97.91
86.05
All Hospitals
%No %Yes %No
2.33
80
20
7.44
67
33
25.35
42
58
9.77
58
42
12.56
53
47
24.19
42
58
6.74
73
27
2.09
87
13
13.95
59
41
SAFE PRACTICE 9 NURSING WORKFORCE:
Implement critical components of a well-designed nursing workforce that mutually reinforce patient safeguards, including the following:
 A nurse staffing plan with evidence that it is adequately resourced and actively managed and that its effectiveness is regularly evaluated
with respect to patient safety.
 Senior administrative nursing leaders, such as a Chief Nursing Officer, as part of the hospital senior management team.
 Governance boards and senior administrative leaders that take accountability for reducing patient safety risks related to nurse staffing
decisions and the provision of financial resources for nursing services.
 Provision of budgetary resources to support nursing staff in the ongoing acquisition and maintenance of professional knowledge and skills.
NURSING WORKFORCE
9.1a
9.1b
9.1c
9.2a
9.2b
9.2c
9.2d
9.2e
9.2f
9.3a
9.3b
Page 10 of 51
100
86.36
85.46
98.35
85.54
30.10
Your Hospital's
Responses
Yes or No
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Your
Performance
Group
%Yes
90.31
89.53
70.16
93.02
98.45
95.74
86.43
93.41
84.50
98.45
94.19
%No
9.69
10.47
29.84
6.98
1.55
4.26
13.57
6.59
15.50
1.55
5.81
Top
Performance
Group
%Yes
95.53
99.30
96.98
99.53
99.53
99.53
98.84
99.30
97.21
99.77
100
%No
4.47
.70
3.02
.47
.47
.47
1.16
.70
2.79
.23
0
All Hospitals
%Yes %No
91
9
88
12
75
25
93
7
98
2
91
9
83
17
89
11
84
16
97
3
92
8
9.3c
9.3d
9.3e
9.3f
9.4a
9.4b
9.4c
9.4d
9.4e
9.4f
9.4g
Page 11 of 51
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
95.47
72.09
90.31
90.70
95.74
94.57
75.19
73.26
80.62
58.14
52.33
4.26
27.91
9.69
9.30
4.26
5.43
24.81
26.74
19.38
41.86
47.67
100
0
99.07 .93
100
0
99.30 .70
99.53 .47
99.77 .23
97.44 2.56
98.37 1.63
99.07 .93
93.95 6.05
87.44 12.56
92
77
87
89
94
94
77
78
84
68
62
8
23
13
11
6
6
23
22
16
32
38
SAFE PRACTICE 12 COMMUNICATION OF CRITICAL INFORMATION:
Ensure that care information is transmitted and appropriately documented in a timely manner and in a clearly understandable form to patients and
to all of the patient’s healthcare providers/professionals, within and between care settings, who need that information to provide continued care.
COMMUNICATION OF CRITICAL INFORMATION
12.1a
12.1b
12.1c
12.1d
12.2a
12.2b
12.2c
12.3a
12.3b
12.3c
12.4a
12.4b
Page 12 of 51
84
84
68.26
83.48
69.74
39.50
Your Hospital's
Responses
Yes or No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Your
Performance
Group
%Yes
88.37
90.70
89.53
63.18
76.36
68.22
67.83
97.29
88.76
56.20
97.29
87.60
%No
11.63
9.30
10.47
36.82
23.64
31.78
32.17
2.71
11.24
43.80
2.71
12.40
Top
Performance
Group
%Yes
99.77
100
100
98.37
99.77
99.77
97.44
100
100
99.07
99.77
98.60
%No
.23
0
0
1.63
.23
.23
2.56
0
0
.93
.23
1.40
All Hospitals
%Yes %No
88
12
89
11
87
13
71
29
82
18
77
23
72
28
94
6
86
14
69
31
95
5
87
13
SAFE PRACTICE 14 LABELING OF DIAGNOSTIC STUDIES:
Implement standardized policies, processes, and systems to ensure accurate labeling of radiographs, laboratory specimens, or other diagnostic
studies, so that the right study is labeled for the right patient at the right time.
LABELING OF DIAGNOSTIC STUDIES
14.1a
14.1b
14.1c
14.2a
14.2b
14.2c
14.3a
14.3b
14.4a
14.4b
Page 13 of 51
15
12
11.1
14.66
11.80
33.90
Your Hospital's
Responses
Yes or No
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Your
Performance
Group
%Yes
82.95
84.88
42.25
69.77
63.57
43.02
86.82
82.56
96.51
78.68
%No
17.05
15.12
57.75
30.23
36.43
59.98
13.18
17.44
3.49
21.32
Top
Performance
Group
%Yes
99.77
99.30
92.79
98.84
98.84
91.86
99.07
99.53
99.53
97.67
%No
.23
.70
7.21
1.16
1.16
8.14
.93
.47
.47
2.33
All Hospitals
%Yes %No
85
15
86
14
60
40
76
24
73
27
58
42
88
12
84
16
96
4
80
20
SAFE PRACTICE 15 DISCHARGE SYSTEMS:
A “discharge plan” must be prepared for each patient at the time of hospital discharge, and a concise discharge summary must be prepared for and
relayed to the clinical caregiver accepting responsibility for post-discharge care in a timely manner. Organizations must ensure that there is
confirmation of receipt of the discharge information by the independent licensed practitioner who will assume the responsibility for care after
discharge.
DISCHARGE SYSTEMS
15.1a
15.1b
15.1c
15.1d
15.2a
15.2b
15.2c
15.3a
15.3b
15.4a
15.4b
15.4c
15.4d
15.4e
Page 14 of 51
25
15.28
17.75
24
19.38
22.50
Your Hospital's
Responses
Yes or No
Yes
Yes
Yes
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Your
Performance
Group
%Yes
79.46
68.60
58.91
37.60
61.24
51.55
41.86
72.09
65.50
55.04
96.90
91.86
95.35
78.29
%No
20.54
31.40
41.09
62.40
38.76
48.45
58.14
27.91
34.50
44.96
3.10
8.14
4.65
21.71
Top
Performance
Group
%Yes
98.14
97.44
94.65
91.86
96.74
95.58
92.33
98.14
98.14
95.12
99.30
99.07
98.60
95.35
%No
1.86
2.56
5.35
8.14
3.26
4.42
7.67
1.86
1.86
4.88
.70
.93
1.40
4.65
All Hospitals
%Yes %No
83
17
74
26
70
30
57
43
73
27
66
34
61
39
78
22
76
24
71
29
96
4
41
9
94
6
81
19
15.4f
15.4g
15.4h
15.4i
Page 15 of 51
Yes
Yes
Yes
Yes
89.15 10.85 97.67 2.33
72.87 27.131 95.58 4.42
89.15 10.85 97.67 2.33
67.83 32.17 86.98 13.02
88
77
90
70
12
23
10
30
SAFE PRACTICE 17 MEDICATION RECONCILIATION:
The healthcare organization must develop, reconcile, and communicate an accurate patient medication list throughout the continuum of care.
MEDICATION RECONCILIATION
17.1a
17.1b
17.1c
17.2a
17.2b
17.2c
17.3a
17.3b
17.3c
17.4a
17.4b
17.4c
17.4d
17.4e
17.4f
Page 16 of 51
35
32.67
30.23
35
30.71
38.00
Your Hospital's
Responses
Yes or No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Your
Performance
Group
%Yes
93.02
94.18
75.97
74.42
69.77
72.09
91.09
91.09
71.71
96.51
84.88
97.67
88.76
96.90
92.64
%No
6.98
5.81
24.03
58.58
30.23
27.91
8.91
8.91
28.29
3.49
15.12
2.33
11.24
3.10
7.36
Top
Performance
Group
%Yes
99.53
100
98.37
99.07
98.84
98.14
98.84
97.67
97.67
99.77
99.07
99.30
96.98
99.77
99.53
%No
.47
0
1.63
.93
1.16
1.86
1.16
2.33
2.33
.23
.93
.70
3.02
.23
.47
All Hospitals
%Yes %No
91
9
96
4
79
21
78
22
77
23
77
23
90
10
90
10
77
23
96
4
88
12
97
3
89
11
97
3
93
7
SAFE PRACTICE 19 HAND HYGIENE:
Comply with current Centers for Disease Control and Prevention Hand Hygiene Guidelines.
HAND HYGIENE
19.1a
19.1b
19.2a
19.2b
19.2c
19.2c
19.3a
19.3b
19.4a
19.4b
Page 17 of 51
30
24
25.30
29.8
26.25
20.70
Your Hospital's
Responses
Yes or No
Yes
No
Yes
Yes
Yes
No
Yes
Yes
Yes
yes
Your
Performance
Group
%Yes
96.51
84.11
75.58
72.48
68.22
81.40
97.67
69.77
97.29
96.90
%No
3.49
15.89
24.42
27.52
31.78
18.60
2.33
30.23
2.71
3.10
Top
Performance
Group
%Yes
99.77
99.30
98.14
99.07
98.84
99.30
99.77
99.30
100
100
%No
.23
.70
1.86
.93
1.16
.70
.23
.70
0
0
All Hospitals
%Yes %No
97
3
86
14
82
18
79
21
79
21
85
15
98
2
76
24
98
2
96
4
SAFE PRACTICE 21 CENTRAIL VENOUS CATHETER-RELATED BLOODSTREAM INFECTION PREVENTION:
Take actions to prevent central line-associated bloodstream infection by implementing evidence-based intervention practices.
CENTRAL VENOUS CATHETER-RELATED BLOODSTREAM
INFECTION PREVENTION
21.0
21.1a
21.1b
21.1c
21.2a
21.2b
21.2c
21.3a
21.3b
21.3c
21.4a
21.4b
Page 18 of 51
30
30
26.16
29.9
27.20
34.40
Your Hospital's
Responses
Yes or No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Your
Performance
Group
%Yes
96.51
95.74
94.96
89.53
76.36
68.99
91.47
92.64
87.98
71.71
94.19
91.86
%No
3.49
4.26
5.04
10.47
23.64
31.01
8.53
7.36
12.02
28.29
5.81
8.14
Top
Performance
Group
%Yes
99.77
99.30
99.53
99.30
99.77
99.30
99.77
99.30
99.53
99.30
99.07
99.77
%No
.23
.70
.47
.70
.23
.70
.23
.70
.47
.70
.93
.23
All Hospitals
%Yes %No
98
2
96
4
95
5
88
12
83
17
78
22
88
12
94
6
89
11
78
22
95
5
93
7
SAFE PRACTICE 23 PREVENTION OF VENTILATOR ASSOCIATED COMPLICATIONS:
Take actions to prevent complications associated with ventilated patients: specifically, ventilator-associated pneumonia, venous thromboembolism,
peptic ulcer disease, dental complications, and pressure ulcers.
PREVENTION OF VENTILATOR ASSOCIATED COMPLICATIONS
23.0
23.1a
23.1b
23.2a
23.2b
23.2c
23.3a
23.3b
23.3c
23.4a
23.4b
23.4c
23.4d
Page 19 of 51
20
20
15.80
19.58
17.53
47.00
Your Hospital's
Responses
Yes or No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Your
Performance
Group
%Yes
92.25
90.70
85.27
69.77
61.24
86.05
88.37
67.83
75.97
85.27
86.05
58.91
89.15
%No
7.75
9.30
14.73
30.23
38.76
13.95
11.63
32.17
24.03
14.73
13.95
41.09
10.85
Top
Performance
Group
All Hospitals
%Yes %No %Yes %No
97.67 2.33
92
8
97.21 2.79
90
10
95.51 4.49
84
16
96.98 3.02
76
24
96.05 3.95
72
28
96.51 3.49
83
17
96.74 3.26
86
14
3.49 4.49
72
28
96.74 3.26
79
21
96.05 3.95
84
16
97.67 2.33
87
13
83.67 16.33
65
35
96.74 3.26
87
13
SAFE PRACTICE 25 CATHETER ASSOCIATED URINARY TRACT INFECTION PREVENTION:
Take actions to prevent catheter-associated urinary tract infection by implementing evidence-based intervention practices.
CATHETER ASSOCIATED URINARY TRACT INFECTION PREVENTION
25.1a
25.1b
25.2a
25.2b
25.2c
25.3a
25.3b
25.4a
25.4b
25.4c
Page 20 of 51
30
30
21.27
29.02
23.82
56.30
Your Hospital's
Responses
Yes or No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Your
Performance
Group
%Yes
87.21
70.54
59.69
53.88
65.89
92.25
56.59
89.15
55.43
79.46
%No
12.19
29.46
40.13
46.12
34.11
7.75
43.41
10.85
44.57
20.54
Top
Performance
Group
%Yes
93.72
92.09
94.65
93.95
90.70
94.19
93.02
95.35
93.95
93.72
%No
6.28
7.91
5.35
6.05
9.30
5.81
6.98
4.65
6.05
6.28
All Hospitals
%Yes %No
89
11
74
26
72
28
69
31
73
27
89
11
69
31
90
10
67
33
83
17
SAFE PRACTICE 28 REDUCE OCCURANCE OF VENOUS THROMBOEMBOLISM (VTE):
Evaluate each patient upon admission, and regularly thereafter, for the risk of developing venous thromboembolism. Utilize clinically appropriate,
evidence-based methods of thromboprophylaxis.
REDUCE OCCURANCE OF VTE
28.1A
28.1b
28.2a
28.2b
28.2c
28.3a
28.3b
28.4a
28.4b
Page 21 of 51
25
25
19.87
24.61
21.07
45.10
Your Hospital's
Responses
Yes or No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Your
Performance
Group
%Yes
90.31
75.58
72.09
58.53
76.36
88.76
80.62
85.66
87.98
%No
9.69
24.42
27.91
41.47
23.64
11.24
19.38
14.34
12.02
Top
Performance
Group
%Yes
95.12
93.49
94.88
93.72
93.72
95.12
93.95
93.02
93.47
%No
4.88
6.51
5.12
6.28
6.28
4.88
6.05
6.98
6.53
All Hospitals
%Yes %No
91
9
78
22
79
21
70
30
77
23
90
10
82
18
87
13
84
16
SAFE PRACTICE 29 ENSURE ANTICOAGULATION THERAPY IS EFFECTIVE AND SAFE:
Take actions to prevent catheter-associated urinary tract infection by implementing evidence-based intervention practices.
ENSURE ANTICOAGULATION THERAPY IS EFFECTIVE AND SAFE
29.1a
29.1b
29.1c
29.1d
29.2a
29.2b
29.2c
29.3a
29.3b
29.3c
29.3d
29.4a
29.4b
29.4c
Page 22 of 51
35
30
24.38
32.49
26.48
48.10
Your Hospital's
Responses
Yes or No
Yes
Yes
Yes
No
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Your
Performance
Group
%Yes
92.25
86.82
65.89
50.39
64.73
55.04
51.55
78.29
80.23
93.41
71.32
86.82
25.58
73.64
%No
7.75
13.18
34.11
49.61
35.27
44.96
48.45
21.71
19.77
6.59
28.68
13.18
74.42
26.36
Top
Performance
Group
%Yes
93.35
44.19
86.51
87.44
92.56
92.33
88.37
88.14
93.72
93.72
83.72
91.63
63.26
91.16
All Hospitals
%No %Yes %No
6.65
92
8
55.81
86
14
13.49
70
30
12.56
63
37
7.44
70
30
7.67
67
33
11.63
63
37
11.86
77
23
6.28
82
18
6.28
92
8
16.28
72
28
8.37
86
14
36.74
38
62
8.84
76
24
INTENTIALLY LEFT BLANK
Page 23 of 51
2010 LEAPFROG SAFE PRACTICES
Practice #1 – Leadership Structures and Systems
AWARENESS
1.1
ACCOUNTABILITY
1.2
(page numbers reference NQF Safe Practices for Better Healthcare – 2010 Update report)
In regard to raising the awareness of key stakeholders to our organization’s efforts to improve patient safety, the following actions related to
identification and mitigation of risk and hazards have been taken:
a
Board (governance) minutes for the past 12 months reflect regular communication regarding risks, hazards, culture measurement, and
progress towards resolution of safety and quality problems. (p.75)
b
patients and family of patients are formally involved in safety and quality committees that meet on a regularly scheduled basis. (p.75)
c
the community was made aware in the past 12 months of ongoing efforts to improve safety and quality in the organization. (p.75)
d
all staff and independent practitioners were made aware in the past 12 months of ongoing efforts to reduce risks and hazards and to
improve patient safety and quality in the organization. (p.75)
In regard to holding the Board, senior management, mid-level management and physician leadership, and frontline caregivers directly
accountable for results related to mitigating unsafe practices, the organization has done the following:
a
an integrated, patient safety program has been in place for at least the past 12 months providing oversight and alignment of safe practices
activities. (p.76)
b
a patient safety officer (PSO) has been appointed and communicates regularly with the Board (governance) and senior administrative
leadership; the PSO is the primary point of contact in the program. (p.76)
c
Performance has been documented in performance reviews and/or compensation incentives for all levels of hospital management and
care-giving noted above. (p.76)
d
the interdisciplinary patient safety team communicated regularly with management regarding root cause analyses, progress in meeting
safety goals, and providing team training to caregivers. Actions have been documented in meeting minutes. (pp.76-77)
Page 24 of 51
e
ABILITY
1.3
1.4
the facility reported adverse events to external mandatory or voluntary programs. (p.77)
In regard to implementation of the patient safety program, the Board (governance) and senior administrative leaders have provided resources
to cover the implementation during the last 12 months, and:
a
patient safety program budgets were sufficiently resourced to support the program, staffing, and technology investment. (p.77)
b
documentation of these budgets is available for review by external organizations. (p.77)
Structures and systems for assuring that leadership is taking direct and specific actions have been in place for the past 12 months, as evidenced
by:
ACTION
a
CEO and senior administrative leaders are personally engaged in reinforcing patient safety improvements, e.g., “walk-arounds”, holding
patient safety meetings, reporting to the Board (governance). Calendars reflect allocated time. (p.78)
b  CEO has engaged unit, service-line, departmental and midlevel management leaders in patient safety improvement actions. (p.79)
c
CEO established structure for input into patient safety program by independent medical practitioners. Input documented in meeting
minutes or materials. (p.79)
Practice #2 –Culture Measurement, Feedback, and Intervention
2.1
In regard to Culture Measurement, our organization has done the following within the last 24 months:
AWARENESS
a
conducted a safety and quality survey using a nationally recognized tool with consideration of validity, consistency and reliability, with a
sample that accounts for 50% of the aggregated care delivered to patients within the facility, and covers the high patient safety risk units or
departments.(p.88)
If this item ‘a’ not checked, no other items in this Practice #2 may be checked.
b
portrayed the results of the culture survey in a report, which reflects both hospital-wide and individual unit level results. (p.88)
Page 25 of 51
ACCOUNTABILITY
2.2
ABILITY
2.3
2.4
In regard to accountability for improvements in the measurement of the culture of safety, our organization has done the following within the
last 24 months:
a
involved senior administrative leadership in the identification and selection of sampled units; and, in the selection of an appropriate tool
for measuring the culture of safety. (p.88)
b
Shared the results of the culture measurement survey with the Board (governance) and senior administrative leadership in a formal report
and discussion. (p.88)
In regard to the culture of safety measurement, the organization has done the following (or has had the following in place) within the last 12
months:
a
conducted staff education program(s), on methods to improve the culture of safety or team training development programs, based on
survey results. Training was documented in personnel or other administrative records. (p.89)
b
included the costs of annual culture measurement activities in the patient safety program budget. (p.88)
In regard to culture measurement, feedback, and interventions, our organization has done the following or has had the following in place within
the last 12 months:
a
developed or implemented explicit, hospital-wide organizational policies and procedures reflecting regular culture measurement (p.88)
OR
ACTION
implemented strategies for improving culture based on survey results. (p.88)
b
disseminated the results of the survey widely across the institution, with follow-up meetings held by senior administrative leadership with
the sampled units. (p.88)
c
identified process improvements based on the survey results, which were measured, monitored and shared with senior administrative
leadership. (p.88)
Page 26 of 51
Practice #3 –Teamwork Training and Skill Building
3.1
In regard to teamwork training and skill building, our organization has done the following within the last 12 months:
a
conducted a literature review of the teamwork training impact in healthcare or in other settings. (p.101)
OR
AWARENESS
conducted a review of available teamwork training programs in progressive organizations. (p.99)
ACCOUNTABILITY
3.2
ABILITY
3.3
b
informed senior management, mid-level management and physician leadership about the need for teamwork training and skill building,
and/or possible resources from progressive organizations. (pp.97-98)
c
conducted an assessment of high patient safety risk areas by an Interdisciplinary Patient Safety Team to determine specific processes in
need of teamwork improvement. Those processes were identified to senior administrative leadership. (p.97)
d
assessed the organizational need for rapid response systems and any associated training. (p.97)
In regard to leadership being held accountable for the demonstration of teamwork skills in the organization, our organization has done the
following within the last 12 months:
a
determined, through a literature review or an assessment, a set of targeted units or service lines. These units/lines were identified by the
CEO to the Board (governance), senior managers, and medical staff. (p.97)
b
provided basic teamwork trainingi to the Board (governance), senior managers, medical staff, mid-level management, and frontline nurses.
Training was documented in personnel records. (p.96)
In regard to effective teamwork training and skill building, our organization has done the following within the last 12 months:
a
resourced patient safety program budgets in a sufficient manner to support the assessment of need and team training activities.
b
provided clinical staff and licensed independent practitioners in the hospital-targeted units detailed teamwork training and skill building.
Participation was documented. (p.96)
Page 27 of 51
ACTION
3.4
Effective team-centered interventions were either in place or were initiated in the past 12 months, as evidenced by:
a
notation in board minutes documenting that the identified performance improvement targets were being addressed. (p.97)
b
evaluation or documentation of unit or service line results for teams that had received the team training intervention during the past 12
months. (pp.97-98)
Practice #4 –Identification and Mitigation of Risks and Hazards
AWARENESS
4.1
ACCOUN
TABILITY
4.2
Within the last 12 months our organization has done the following:
a
assessed risks and hazards to patients by reviewing retrospective sources: serious and sentinel event reporting; root cause analyses for
adverse events; independent comparative mortality and morbidity information with the hospital’s performance; patient safety indicators;
trigger tools; hospital accreditation surveys; risk management and filed litigation; anonymous internal complaints; and, complaints filed
with state/federal authorities; and based on the findings documented recommended actions. (p.105)
b
assessed risks and hazards to patients using prospective identification tools: Failure Modes and Effects Analysis (FMEA) and/or
Probabilistic Risk Assessment, and has recommendations for improvement documented. (p.106)
c
assessed their defined mitigation efforts based on their own risk profile, and has recommendations for improvement documented. (p.107)
d
integrated results from the three assessments, noted in (a), (b) and (c) above. Results have been shared widely across the organization,
from the Board (governance) to front-line caregivers. (p.107) This item may not be checked unless all items 4.1a, b, c are checked.
Leadership is accountable for identification of risks, hazards and mitigation efforts in the past year, as evidenced by:
a
approval of an action plan by the CEO and the Board (governance) for undertaking the assessments of risk, hazards and for the mitigation
of risk for patients. (p.106)
Page 28 of 51
b
incorporation of the identification and mitigation of risks into performance reviews.
OR
outlined financial incentives for leadership and the Patient Safety Officer for identifying and mitigating risks to patients as identified in the
approved action plan.
ABILITY
4.3
ACTION
4.4
In regard to developing the ability to appropriately assess risk and hazards, the organization has done the following or had in place during the
last 12 months:
a
resourced patient safety program budgets sufficiently to support ongoing risk and hazard assessments and programs for reduction of risk.
b
provided managers at all levels with training on the tools for monitoring risk in their areas; senior managers have received training in the
integration of risk and hazard information across the organization. Training was documented. (pp.107-108)
Structures and systems for assuring that direct and specific actions have taken place to mitigate risks for the past 12 months, include:
a
provided risk identification training to the high risk patient safety units such as: emergency department, labor and delivery, ICUs, and
operating rooms. (p.106)
b
established or already had in place a structure, developed by the CEO and senior leadership, for gathering all information related to risks,
hazards and mitigation efforts within the organization with input from all levels of staff within the organization and from patients and their
families. (p.110)
Practice #5 – Informed Consent
AWARE
NESS
5.1
In regard to the quality of the Informed Consent process for all patients, our organization has done the following or has had the following in
place within the last 12 months:
a
conducted an educational initiative to make clinicians and administration aware of the frequency and severity of poor quality informed
consent episodes and has identified the opportunities for improvement in this area. (p.122)
Page 29 of 51
ACCOUNTABILITY
5.2
ABILITY
5.3
ACT
ION
5.4
b
completed an evaluation of the frequency and severity of episodes tied to poor informed consent processes.
c
submitted a report to the Board (governance) with recommendations for measurable improvement targets. (p.122)
a
held clinical leadership directly accountable for improvements in performance through performance reviews or compensation. (p.122)
b
held the person responsible for patient safety directly accountable for improvements in performance through performance reviews or
compensation.
c
reported to the Board (governance) the results of the measurable improvement targets.
a
conducted staff education/knowledge transfer and skill development programs (e.g., use of the “teach back method”), with attendance
documented. (p.122)
b
revised all consent forms to 5th grade level or lower using simple sentences in the preferred language of the patient. (p.120)
c
provided a qualified medical interpreter or reader to assist patients with limited English proficiency, limited health literacy, and visual or
hearing impairments. (p.120)
In regard to the quality of the Informed Consent process for all patients, our organization has done the following within the last 12 months, or
has had the following in place during the last 12 months and updates are made regularly:
a
implemented hospital-wide policies and procedures to address this Safe Practice. (pp.120-123)
Page 30 of 51
b
Implemented a hospital-wide performance improvement program that incorporates best practices and includes “teach back” methods
(pp.120-123)
OR
monitored a previously implemented hospital-wide performance improvement program that measures, and demonstrates full
achievement of, the impact of this specific Safe Practice. (pp.120-123)
Practice #6 – Life Sustaining Treatment
AWARENESS
6.1
ACCOUNTABILITY
6.2
In regard to performing unwanted life sustaining treatment or withholding resuscitation, our organization has done the following or has had the
following in place within the last 12 months:
a
completed a review of the literature and identified specific best practices for process redesign.
b
conducted an educational initiative to make clinicians and administration aware of the frequency and severity of performing unwanted life
sustaining treatment. (pp.128-130)
c
submitted a report to the Board (governance) with recommendations for measurable improvement targets.
a
held clinical leadership directly accountable for improvements in performance through performance reviews or compensation.
b
compensation.
c
Page 31 of 51
ABI
LITY
6.3
a
conducted staff education and skill development programs, with attendance documented.
In regard to performing unwanted life sustaining treatment or withholding resuscitation, our organization has done the following within the last
12 months or has had the following in place during the last 12 months and updates are made regularly:
a
implemented hospital-wide policies and procedures to address this Safe Practice. (pp.128-130)
b
implemented a hospital-wide performance improvement program that measures the impact of this specific Safe Practice (pp.128-130)
ACTION
6.4
OR
achievement of, the impact of this specific Safe Practice. (pp.128-130)
Practice #9 – Nursing Workforce
AWARENESS
9.1
In regard to ensuring adequate and competent nursing staff service and nursing leadership at all levels, our organization has done the following
or has had the following in place within the last 12 months:
a
held at least one educational meeting for clinicians, senior management, midlevel management, and line management specifically related
to the areas of patient safety and adequate nurse staffing effectiveness. (p.155)
b
performed a risk assessment and an evaluation of the frequency and severity of adverse events that can be related to nurse staffing.
(p.155)
c
Page 32 of 51
ACCOUNTABILITY
9.2
ABILITY
9.3
a
held clinical leadership directly accountable for improvements in performance through performance reviews or compensation. (p.155)
b
included senior nursing leadership as part of the hospital senior management team. (p.155)
c
reported performance metrics related to this area to governance. (p.155)
d
held the Board (governance) and senior administrative leadership accountable for reducing patient safety risks related to nurse staffing
decisions. (p.155)
e
held the Board (governance) and senior administrative leadership accountable for the provision of financial resources for nursing services.
(p.155)
f
reported to the Board (governance) the results of the measurable improvement targets. (p.155)
a
conducted staff education on maintaining and improving competencies specific to assigned job duties related to the safety of the patient,
with attendance documented. (p.155)
b
allocated dedicated and compensated staff time to reduce adverse event rates related to staffing levels or competency issues.
c
allocated staff time to work on this safe practice.
d
documented expenses incurred during the past year tied to this safe practice.
e
budgeted for improving performance and optimizing staffing levels and skill levels. (p.155)
f
 budgeted financial resources approved by governance for the provision of optimal nurse staffing. (p.155)
Page 33 of 51
9.4
within the last 12 months or has had the following in place during the last 12 months and updates are made regularly:
a
implemented policies and procedures, with input from nurses, to ensure that adequate nursing staff-to-patient ratios are achieved. (p.154)
b
developed policies and procedures for effective staffing targets that specify number, competency and skill mix of nursing staff. (p.155)
c
implemented a performance improvement project that minimizes the risk to patients from less than optimal staffing levels (p.155)
ACTION
OR
achievement of, the impact of this specific Safe Practice. (p.155)
d
measured and monitored the above process improvements based on established targets.
e
collected and analyzed data of actual unit-specific nurse staffing levels on a quarterly basis to identify and address potential patient safetyrelated staffing issues. (p.155)
f
provided unit-specific reports of potential patient safety-related staffing issues to senior administrative leadership and the Board
(governance) at least quarterly. (p.155)
g
provided reports at least annually to the public through the appropriate organizations. (p.155)
Practice #12 – Communication of Critical Information
12.1
In regard to timely and understandable communication of patient care information to the patient and his/her care providers, our organization
has done the following or has had the following in place within the last 12 months:
AW
ARE
NES
S
a
completed a review of the literature and identified specific best practices for process redesign. (pp.183-184)
Page 34 of 51
ACCOUNTABILITY
12.2
ABILITY
12.3
12.4
b
conducted an educational meeting for administrative or clinical personnel addressing the area. (p.179)
c
performed a hospital-wide evaluation of adverse events related to communication gaps and/or failures regarding critical test results.
(p.178)
d
a
b
compensation.
c
a
conducted staff education and skill development programs addressing communication of patient information to and between caregivers
and between caregivers and patients/legal guardians within the constraints of federal and state HIPAA requirements, with attendance
documented. (p.178)
b
allocated dedicated staff time to focus on all aspects of this Safe Practice.
c
dedicated budget tied to this safe practice.
has done the following within the last 12 months or has had the following in place during the last 12 months and updates are made regularly:
Page 35 of 51
ACTION
a
implemented hospital-wide policies and procedures to address this Safe Practice, including processes for communicating critical results to
licensed healthcare providers during the patient’s stay and for communicating critical results that are completed after the patient has been
discharged from the organization.
b
implemented a hospital-wide performance improvement program that measures the impact of this specific Safe Practice
OR
achievement of, the impact of this specific Safe Practice.
Practice #14 – Labeling of Diagnostic Studies
AWARENESS
14.1
ACCOUN
TABILITY
14.2
In regard to ensuring accurate labeling of diagnostic studies including radiographs, laboratory specimens or other diagnostic studies, our
organization has done the following or has had the following in place within the last 12 months:
a
conducted an educational initiative to make clinicians and administration aware of the frequency and severity of adverse events resulting
from communication breakdowns including mislabeled radiographs, laboratory specimens or other diagnostic studies. (p.192)
b
performed a hospital-wide evaluation of adverse events related to mislabeling of radiographs, laboratory specimens or other diagnostic
studies. (p.192)
c
a
held senior administrative leadership and clinical leadership directly accountable for improvements in performance through performance
reviews or compensation.
Page 36 of 51
ABILITY
14.3
ACTION
14.4
b
compensation.
c
a
conducted staff education and skill development programs, with attendance documented. (p.193)
b
allocated compensated staff time to ensure that the standardized protocols are in place and adhered to.
organization has done the following within the last 12 months or has had the following in place during the last 12 months and updates are made
regularly:
a
implemented standardized protocols and explicit organizational policies and procedures to prevent the mislabeling of specimens or
diagnostic studies. (p.192)
b
implemented a hospital-wide performance improvement program that measures the impact of this specific Safe Practice (p.192)
OR
Practice #15 – Discharge Systems
15.1
In regard to adverse events resulting from non-standardized, fragmented or ineffective information transfer at the time of patient discharge,
our organization has done the following or has had the following in place within the last 12 months:
Page 37 of 51
AWARENESS
ACCOUNTABILITY
15.2
ABILITY
15.3
15.4
a
b
conducted an educational initiative to make clinicians and administration aware of the frequency and severity of adverse events resulting
from errors in transfer of patient specific clinical information to the patient and ambulatory or other care providers responsible for postdischarge care. (p.199)
c
performed a hospital-wide evaluation of the frequency and severity of adverse events regarding disconnects in information transfer at the
time of patient-discharge. (p.199)
d
a
b
compensation
c
a
invested in relevant skill development programs that address this issue in whole or in part.
b
allocated compensated caregiver staff time and dedicated line item budget resources to invest in best practices development for the
organization’s patient discharge system.
our organization has done the following within the last 12 months or has had the following in place during the last 12 months and updates are
made regularly:
Page 38 of 51
a
implemented a hospital-wide performance improvement program that measures the impact of this specific Safe Practice (p.199)
ACTION
OR
b
established and implemented policies, procedures, and systems regarding discharge planning and appropriate follow-through.
The discharge planning policies, procedures, and systems in item (b) include:
Items 15.4 c-e may not be checked unless item 15.4b is checked.
c
delineation of roles and responsibilities. (p.198)
d
preparation for discharge begins at admission and continues throughout hospitalization. (p.198)
e
standardization of communication methods, including information flow from the primary care provider (PCP) or referring caregiver, on
patient admission and back to the PCP upon discharge. (p.199)
Discharge Plans were completed prior to discharge and
f
 provided to the provider taking responsibility for the patient’s care post discharge. (p.199)
g
included the specific minimum requirements outlined in this Safe Practice. (p.199)
h
made original source documents (e.g. laboratory, radiology, or medication administration reports) available to the clinician when
transcribing information from one document to another. (p.199)
i
 ensured receipt of discharge information by providers/caregivers assuming responsibility for post discharge care. (p.199)
Page 39 of 51
Practice #17 – Medication Reconciliation
AWARENESS
17.1
ACCOUNTABILITY
17.2
a
b
performed a hospital-wide evaluation of the frequency and severity of adverse drug events in our patient population.
c
In regard to adverse drug events and the medication reconciliation process, our organization has done the following or has had the following in
a
held senior administrative leadership directly accountable for improvements in performance through performance reviews or
compensation.
b
compensation.
c
a
conducted staff education and skill development programs, with attendance documented. (p.221)
b
conducted an education program for all newly hired clinicians on the importance of medication reconciliation, with attendance
documented. (p.219)
c
allocated compensated caregiver staff time and dedicated line item budget resources for best practices development for the organization’s
medication reconciliation system. (p.222)
ABILITY
17.3
Page 40 of 51
17.4
In regard to adverse drug events and the medication reconciliation process, our organization has done the following within the last 12 months
or has had the following in place during the last 12 months and updates are made regularly:
a
developed explicit, hospital-wide organizational policies and procedures regarding medication reconciliation.
b
OR
ACTION
achievement of, the impact of this specific Safe Practice.
c
implemented standardized processes to obtain and document a complete list of each patient’s current medications at the beginning of
each episode of care. (p.219)
d
implemented standardized processes to ensure that a complete list of the patient’s medications is communicated to the next provider of
service, including the documentation of communication between providers. (p.220)
e
implemented standardized processes to provide the patient, and family as needed, a current list and explanation of the patient’s reconciled
medications upon the patient leaving the organization’s care. (p.220)
f
reconciled medications for any changes in the patient’s care or health status. (p.220)
Practice #19 – Hand Hygiene
AWARENESS
19.1
In regard to hospital-acquired infections related to inadequate hand hygiene, our organization has done the following or has had the following in
a
undertaken a hospital-wide educational effort addressing the frequency and severity of hospital-acquired infections resulting from
inadequate hand hygiene within our patient population and potential impact of performance improvement practices related to the absence
of or inadequate hand hygiene. (p.250)
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b
ACCOUNTABILITY
19.2
ABILITY
19.3
ACTION
19.4
a
Held clinical leadership directly accountable for this patient safety area through performance reviews or compensation.
b
Held senior administrative leadership directly accountable for this patient safety area through performance reviews or compensation.
c
Held the person responsible for patient safety directly accountable for improvements in performance through performance reviews or
compensation.
d
a
conducted staff education/knowledge transfer and skill development programs, with attendance documented. (p.251)
b
documented expenditures on staff education related to this Safe Practice in the previous year.
In regard to hospital-acquired infections related to inadequate hand hygiene, our organization has done the following within the last 12 months
or has had the following in place during the last 12 months and updates are made regularly:
a
implemented explicit organizational policies and procedures across the entire organization to prevent hospital-acquired infections due to
inadequate hand hygiene including CDC guidelines with category IA, IB, or IC evidence. (p.250)
Page 42 of 51
b
implemented a formal performance improvement program addressing hospital-acquired infections focused on hand hygiene compliance,
with regular performance measurement and tracking improvement (pp.250-251)
OR
monitored a previously implemented hospital-wide performance improvement program that measures, and demonstrates full achievement
of, the impact of this specific Safe Practice. (pp.250-251)
Practice #21 – Central Venous Catheter-Related Bloodstream Infection Prevention
Does your facility care for patients with central lines?
○ Yes
○ No
AWARENESS
If Yes, continue with the remainder of this Safe Practice. Otherwise, skip it; the Practice does not apply.
21.1
In regard to central venous catheter-related bloodstream infections, our organization has done the following or has had the following in place
within the last 12 months:
21.2
a
performed a hospital-wide evaluation of the frequency of incidents of central venous catheter-related bloodstream infections. (p.268)
b
completed a literature review and identified specific best practices for process redesign.
c
Page 43 of 51
ACCOUNTABILITY
ABILITY
21.3
ACTION
21.4
a
b
compensation.
c
a
conducted staff education/knowledge transfer and skill development programs on central venous catheter-related bloodstream infection
prevention, with attendance documented.
b
allocated compensated staff time to work on this Safe Practice.
c
documented or can document expenses incurred during the past year tied to this Safe Practice.
In regard to central venous catheter-related bloodstream infections, our organization has done the following within the last 12 months or has
had the following in place during the last 12 months and updates are made regularly:
a
implemented explicit organizational policies and procedures that include appropriate adult or pediatric specific bundle elements to prevent
the occurrence of central venous catheter-related blood stream infections.
b
implemented a formal performance improvement program addressing central venous catheter-associated blood stream infections (with
regular performance measurement and tracking improvement) (pp. 266-267)
OR
of, the impact of this specific Safe Practice. (pp.266-267)
Page 44 of 51
Practice #23 – Prevention of Ventilator Associated Complications
Does your facility care for patients on ventilators?
○ Yes
○ No
AWARENESS
If Yes, continue with the remainder of this Safe Practice. Otherwise, skip it; the Practice does not apply.
23.1
In regard to complications associated with ventilator use, our organization has done the following or has had the following in place within the
last 12 months:
ACCOUNTABILITY
23.2
23.3
a
conducted an evaluation of the frequency and severity of ventilator-associated complications in our patient population and communicated
findings to senior and clinical leadership. (p.280)
b
last 12 months:
a
b
compensation.
c
last 12 months:
Page 45 of 51
ABILITY
a
ACTION
23.4
conducted a staff education/ knowledge transfer and skill development programs on best practices and strategies to reduce complications
with attendance documented.
The organization:
b
documented or can document expenses incurred during the past year tied to this Safe Practice. (p.284)
c
allocated compensated caregiver staff time to work on this Safe Practice.
In regard to complications associated with ventilator use, our organization has done the following within the last 12 months or has had the
following in place during the last 12 months and updates are made regularly:
a
documented evidence that all ventilated patients are included in an appropriate adult or pediatric specific bundle or prevention plan that is
clearly documented in the medical record. (p.281)
b
implemented explicit organizational policies for the disinfection, sterilization, and maintenance of respiratory equipment that are aligned
with evidenced base guidelines. (p.280)
c
documented evidence that all ventilated patients and/or their families have been educated on prevention measures involved in the care of
the ventilated patient. (p.280)
d
implemented a formal performance improvement program with regular performance measurement and tracking improvement addressing
ventilator associated complication prevention and compliance with prevention strategies (p.283)
OR
of, the impact of this specific Safe Practice. (p.283)
Page 46 of 51
Practice #25 –Catheter Associated Urinary Tract Infection Prevention
AWARENESS
Note: This Safe Practice does not apply to pediatric hospitals.
25.1
In regard to catheter associated urinary tract infections, our organization has done the following or has had the following in place within the last
12 months:
ACCOUNTABILITY
25.2
ABILITY
25.3
25.4
a
performed a hospital-wide evaluation of the frequency of incidents of catheter associated urinary tract infections and communicated
findings to senior and clinical leadership. (p.307)
b
12 months:
a
b
compensation.
c
12 months:
a
conducted staff education/knowledge transfer and skill development programs, including education for all new employees upon hire and
for individuals whose responsibilities now include involvement in these procedures. (p.306)
b
documented or can document expenses incurred during the past year tied to this Safe Practice.
In regard to catheter associated urinary tract infections, our organization has done the following within the last 12 months or has had the
Page 47 of 51
ACTION
a
implemented evidenced based practices across the organization aimed at preventing the occurrence of urinary catheter-related infections.
(pp.306-307)
b
implemented explicit organizational policies to educate patients (or family, as appropriate) that require a urinary catheter about catheter
associated urinary tract infection prevention. (p.306)
c
implemented a formal performance improvement program addressing catheter associated urinary tract infections (with regular
performance measurement and tracking improvement) (p.306)
OR
Practice #28 – Reduce Occurrence of Venous Thromboembolism (VTE)
AWARENESS
28.1
In regard to the problem of developing venous thromboembolism (VTE), and subsequent pulmonary embolism, our organization has done the
following or has had the following in place within the last 12 months:
28.2
a
conducted an educational initiative to make clinicians and other caregivers aware of the need for prevention of venous thromboembolism
and the appropriate prophylaxis. (p.330)
b
submitted a report based on a hospital-wide evaluation and performance improvement process for prophylaxis to the Board (governance)
with recommendations for measurable improvement targets.
ACC
OU
NTA
BILI
TY
a
Page 48 of 51
ABILITY
28.3
ACTION
28.4
b
compensation.
c
reported to the Board (governance) the results of the measurable improvement targets for this practice.
a
had a multidisciplinary team review, and modify if needed, the organization’s protocols for assessment and risk prevention. (p.330)
b
conducted staff education and skill development programs on assessment and selection of appropriate prophylaxis dependent upon patient
risk, with attendance documented. (p.330)
following within the last 12 months or has had the following in place during the last 12 months and updates are made regularly:
a
implemented explicit, hospital-wide, organizational policies and procedures regarding assessment at admission and appropriate prevention
depending on the risk of the patient. (p.330)
b
completed a formal hospital-wide performance improvement program, which includes assessment of patient risk at admission, and the use
of prophylaxis 24 hours before surgery and for high risk medical patients (p.330)
OR
Practice #29 – Ensure Anticoagulation Therapy is Effective and Safe
Page 49 of 51
AWARENESS
29.1
ACCOUNTABILITY
29.2
ABILITY
29.3
In regard to anticoagulation therapy and coordinated care, our organization has done the following or has had the following in place within the
last 12 months:
a
completed a review of the literature and identified specific best practices for process redesign.
b
conducted an educational initiative to make clinicians and administration aware of the importance of careful monitoring by a qualified
health professional, including a coordinated process with dedicated management.
c
conducted a review of patients with long term anticoagulation to assess how well the organization had done in monitoring and supervising
the care they received both within and across boundaries of the hospital.
d
last 12 months:
a
held senior administrative leadership directly accountable for improvements in performance through performance reviews or
compensation.
b
compensation.
c
last 12 months:
a
conducted staff education and skill development programs in monitoring anti-coagulation therapy and bridging techniques to ensure
coordination with community caregivers, with attendance documented.
b
conducted a patient education program for patients and their families on the safety of anticoagulation therapy. (p.339)
Page 50 of 51
ACTION
29.4
c
used approved standardized protocols for the initiation and maintenance of anticoagulation therapy appropriate to the medication used,
the condition being treated, and the potential for medication interactions. (p.339)
d
implemented explicit, hospital-wide, organizational policies and procedures regarding the intensity and level of supervision of patients on
long-term anticoagulants, and the coordination of care across settings. Policy requires documentation of: indication for long-term
anticoagulation, target INR range; duration of anti-coagulation/and or a review date, longitudinal record of INR values and warfarin doses;
and timing of next INR appointment. (p.339)
In regard to anticoagulation therapy and coordinated care, our organization has done the following within the last 12 months or has had the
a
implemented a defined anticoagulation management program to individualize the care provided to each patient receiving anticoagulant
therapy. (p.338)
b
implemented a formal “hospital-to-community” performance improvement program. (p.340)
c
OR
of, the impact of this specific Safe Practice.
Page 51 of 51

2010 sAFE pRACTICE REPORt - Southern Ohio Medical Center

Transcription

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