Patient Safety Initiative (PSI): Hospital Survey Protocol

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

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

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

4. Head scratching…

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

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

7. Russ goes to Baltimore…

8. …and so does Pat

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

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

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

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

13. A Matter of Perspective…

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

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

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

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

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

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

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

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

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

23. IC worksheet: A closer look... • 5 modules • Require surveyors to use active processes (observation, interviews, data collection) - “discovery” • Program and all its components • Strong link with QAPI

24. IC Module 1: Program • Individual(s) in charge of program • Qualifications through training & experience • Nationally recognized guidelines • Integral part of hospital QAPI processes • Promote antibiotic stewardship • Stafftraining; employee health practices

25. Module 1: Antibiotic Stewardship • Prevent transmission of MDROs • Review antimicrobial utilization • Systems to prompt appropriate antibiotic • “Antibiotic time out” - review at 72 hours • Convert IV to oral administration • Recognize novel resistance patterns • Reportable diseases & conditions

26. IC Module 2: General elements • Hand hygiene - observation, monitoring compliance (CDC: make it count) • Safe injection practices & Sharps safety • Medication administration • Single & multi-use vials • PPE • Environmental services

27. IC Module 3: Reprocessing • HLD (+) semi-critical equipment • Identify the equipment • Identify correct (manufacturer’s) processes • Sterilization of critical items • Processes • Controls • Single-use devices

28. IC Module 4: Patient tracers • Urinary catheter • Central venous catheter • Ventilator/respiratory therapy • Spinal injection practices • Point-of-care devices • Isolation & precautions • Surgical procedures

29. IC Module 5: Special care areas • Oncology • Transplantation (organ & tissue) • Severely immunocompromised patients • Reverse isolation Optional: Not all facilities have this capability

30. Who else is in the River…

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

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

33. Questions?