It all started two years ago in July 2009 when a Patient Satisfaction Task- force was appointed by Dean Sayegh with the mission of bringing patient satisfaction at AUBMC to its highest level. Staff engaged, Problems identified, ideas evaluated, solutions proposed, initiatives set, and projects started rolling one after the other. A number of initiatives were implemented: purchasing of a new call center software providing the necessary tools needed to evaluate the technical and manpower efficiency of our telephone operations, revisiting the outpa- tient clinics scheduling system, expanding the parking space and improving its services to include valet parking, assisting the administration in estab- lishing the new Patient Access Unit providing a one-stop admission process, and re-designing of the lab reception area to ensure an efficient patient-friendly service, etc. On a parallel track and as a continuum to the mission of the Patient Satisfaction taskforce, the Patient Affairs Unit was created. The function of this unit revolves around three main pillars: 1. Providing Day-to-Day Core functions: Courtesy Service: greet, welcome, and direct patients and visitors to all services provided at AUBMC. Patient Advocacy Service: proactively identify service delivery problems by conducting daily patient rounds to obtain patient feedback on our services and manage patient concerns in a timely manner. De- velop patient service initiatives to enhance patient satisfaction in coordination with MC Administration and other departments or units. Room Service: provide 24/7 housekeeping service with a plan to extend to full room service. Patient Complaint Management: receive complaints, communicate and follow-up with concerned de- partments, ensure prompt response to complainants, and closure of complaints. Patient Education Program: ensure the availability of Patient Education material on patient care units, TV, and AUBMC website pertinent to the needs of the diverse population we serve at AUBMC. Patient Satisfaction surveys: data gathered is our quality indicator at AUBMC. Revisit the reliability and content validity of our measurement tools along with the survey administration technique and method- ology. Benchmark data internally and externally. 2. Assisting the administration in executing patient satisfaction projects: enhancement of AUBMC cam- pus landscape and flowering, installation of professional and user friendly way-finding signage, renova- tion of the hospital façade, and designing Dress uniforms for all front liners at AUBMC, etc. 3.Instituting multidisciplinary committees aiming at enhancing patient satisfaction, such as Bright Idea Committee. We have started the 1 st steps in a long journey striving for service excellence in a patient-centered care approach. Many challenges will need to be overcome but it is our strong belief that with the solidarity and cooperation of all AUBMC staff we will be able to bring services at AUBMC to the highest standards. Maher Soubra, MD Director Clinical and Patient Affairs LEAPS Newsletter Reviewer: Dr. Saleem Kiblawi Editor: Dr. Rami Mahfouz Layout: Mr. Abdellatif Marini Quality, Accreditation and Risk Management Program Quality, Accreditation and Risk Management Program www.aubmc.org.lb Knowing is not enough; we must apply. Willing is not enough; we must do. PATIENT SATISFACTION: THE BEGINNING OF A LONG JOURNEY TOGETHER… LEAPS LEAPS Newsletter QUALITY ACCREDITATI QUALITY ACCREDITATI ON AND ON AND RISK MANAGEMENT PRO RISK MANAGEMENT PRO GRAM GRAM Quality, Accreditation and Risk Management Program Featured Article 1 Health Information Tech- nology 2 JCI Library of measures 3 Compliance with antibi- otic prophylaxis 3 Risk Management Corner 3 Dep. PI News 4 Miscelleneous 4 Inside This Issue: Volume 6, Issue 2 Johann von Goethe June 2011
Transcript
It all started two years ago in July 2009 when a Patient Satisfaction Task-force was appointed by Dean Sayegh with the mission of bringing patient satisfaction at AUBMC to its highest level.
Staff engaged, Problems identified, ideas evaluated, solutions proposed, initiatives set, and projects started rolling one after the other.
A number of initiatives were implemented: purchasing of a new call center software providing the necessary tools needed to evaluate the technical and manpower efficiency of our telephone operations, revisiting the outpa-tient clinics scheduling system, expanding the parking space and improving its services to include valet parking, assisting the administration in estab-
lishing the new Patient Access Unit providing a one-stop admission process, and re-designing of the lab reception area to ensure an efficient patient-friendly service, etc.
On a parallel track and as a continuum to the mission of the Patient Satisfaction taskforce, the Patient Affairs Unit was created.
The function of this unit revolves around three main pillars:
1. Providing Day-to-Day Core functions: Courtesy Service: greet, welcome, and direct patients and visitors to all services provided at AUBMC. Patient Advocacy Service: proactively identify service delivery problems by conducting daily patient rounds to obtain patient feedback on our services and manage patient concerns in a timely manner. De-velop patient service initiatives to enhance patient satisfaction in coordination with MC Administration and other departments or units. Room Service: provide 24/7 housekeeping service with a plan to extend to full room service. Patient Complaint Management: receive complaints, communicate and follow-up with concerned de-partments, ensure prompt response to complainants, and closure of complaints. Patient Education Program: ensure the availability of Patient Education material on patient care units, TV, and AUBMC website pertinent to the needs of the diverse population we serve at AUBMC. Patient Satisfaction surveys: data gathered is our quality indicator at AUBMC. Revisit the reliability and content validity of our measurement tools along with the survey administration technique and method-ology. Benchmark data internally and externally.
2. Assisting the administration in executing patient satisfaction projects: enhancement of AUBMC cam-pus landscape and flowering, installation of professional and user friendly way-finding signage, renova-tion of the hospital façade, and designing Dress uniforms for all front liners at AUBMC, etc.
3.Instituting multidisciplinary committees aiming at enhancing patient satisfaction, such as Bright Idea Committee.
We have started the 1st steps in a long journey striving for service excellence in a patient-centered care approach. Many challenges will need to be overcome but it is our strong belief that with the solidarity and cooperation of all AUBMC staff we will be able to bring services at AUBMC to the highest standards.
Maher Soubra, MD Director Clinical and Patient Affairs
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Q u a l i t y , A c c r e d i t a t i o n a n d R i s k M a n a g e m e n t P r o g r a m
Featured Article 1
Health Information Tech-nology
2
JCI Library of measures 3
Compliance with antibi-
otic prophylaxis 3
Risk Management Corner 3
Dep. PI News 4
Miscelleneous 4
Inside This Issue:
Volume 6, Issue 2
Johann von Goethe
June 2011
As health information technology (HIT) is increasingly adopted by health care organizations, users must be
mindful of the safety risks and preventable adverse events that these applications can create or perpetuate.
Technology-related adverse events may involve errors of either commission or omission. These unintended ad-
verse events typically stem from human-machine interfaces or organization/system design.
Implementing new clinical information systems can expose latent problems or flawed processes with existing
manual systems; that should be identified and resolved before implementing any new system. Learning to use
new technologies takes time and attention, sometimes placing strain on demanding schedules. The resulting
change to clinical practices and workflows can trigger uncertainty, resentment or other emotions. For example, physicians have
reported a sense of loss of professional autonomy when Computerized Physician Order Entry (CPOE) systems prevent them from
ordering the types of tests or medications they prefer, or force them to comply with clinical guidelines they may not embrace.
Furthermore, clinicians may suffer “alert fatigue” from poorly implemented CPOE systems that generate excessive numbers of drug
safety alerts. This may cause clinicians to ignore even important alerts and to override them, potentially impairing patient safety.
Additionally, safety is compromised when health care information systems are not integrated or updated consistently. Systems not
properly integrated are prone to data fragmentation because new data must be entered into more than one system. For exam-
ple, when the CPOE system is not interfaced with the pharmacy system, each order must be printed manually and then electroni-
cally transcribed into the pharmacy system. This might lead to transcription and communication errors. Moreover, if data are not
updated in the various systems, records become outdated, incomplete or inconsistent.
Joint Commission suggested actions
Below are some of the suggested actions to help prevent patient harm related to the implementation and use of HIT
and converging technologies.
1. Examine workflow processes and procedures for risks and inefficiencies prior to any technology implementation.
2. Actively involve clinicians and staff who will ultimately use or be affected by the technology in all project phases.
3. Assess your organization’s technology needs beforehand.
4. Prior to taking a technology live, ensure that all standardized order sets and guidelines are developed, tested on
paper, and approved by the Pharmacy and Therapeutics Committee (or institutional equivalent).
5. Develop a graduated system of safety alerts in the new technology that helps clinicians determine urgency and relevance.
6. Develop a system that mitigates potential harmful CPOE drug orders by requiring departmental or pharmacy review and sign
off on orders that are created outside the usual parameters.
7. To improve safety, provide an environment that protects staff involved in data entry from undue distractions when using the
technology.
8. Re-evaluate the applicability of security and confidentiality protocols as more medical devices interface with the IT network.
Resources:
The Joint Commission (December 11, 2008). Issue 42: Safely implementing health information and converging technologies.
Abdellatif Marini, MS Quality Review Analyst
Page 2 L E APS NE W SL ETT E R
Implementation of Health Information Technology – Safety Perspective
Risk Management Corner
Page 3 L E APS NE W SL ETT E R
SBAR Communication Technique
The intent statement of the International Patient safety Goal # 2 in the JCI standards is:
“Effective communication, which is timely, accurate, complete, unambiguous, and understood by the recipient, reduces
errors and results in improved patient safety”
The most recommended approach to achieve the above is by using the SBAR communication technique:
The Situation-Background-Assessment-Recommendation (SBAR) technique was developed by Kaiser Permanente of Colorado, and
has been increasingly adopted by hospitals throughout the US to facilitate proper communication among healthcare professionals.
SBAR may be used to report a situation that requires immediate action or to define the elements of a hand over on a patient from
one caregiver to another, and is also used in quality improvement reports.
SituationSituation: When calling a healthcare provider to report a change in the patient’s condition, the staff describes what is happening at
the present time that has warranted this communication.
BackgroundBackground: The staff includes relevant background information specific to the situation such as patient’s diagnosis, mental status,
current vital signs, pain level, etc.
AssessmentAssessment: The staff offers an analysis of the problem and to convey more extensive data about the patient such as changes from
prior assessments.
RecommendationRecommendation: The staff states what he or she thinks would help resolve the situation. This might be phrased in the form of a ques-
tion: “Do you think we should give him a medication, perform lab work, do an x-ray, transfer to another unit, etc.?
For more information, see www.ihi.org, and search for “SBAR”.
Khalil Rizk, MHA, CPHQ
Quality, Accreditation and Risk Manager
Compliance with Prophylactic Antibiotics Prior to Surgery
Prophylactic antibiotic is a requirement for
all clean and clean-contaminated proce-
dures in order to reduce the incidence of
surgical wound infection. Timing of antibiotic
administration is critical to efficacy. The first
dose should always be given before the
procedure, preferably within 30 – 60 minutes
before incision as per the AUBMC policy “Antimicrobial Prophylaxis” (PCI-023). The policy has a set of
guidelines on appropriate choice of prophylactic antibiotic per
clinical specialty.
During the month of February 2011, a retrospective review was
conducted on all patients operated during the month of January
2011 to check the prophylactic antibiotic use process at the
Medical Center. The appropriate choice of antibiotic as well as
appropriate timing of administration was checked by the re-
viewer. A random sample of 73 (10%) medical records was re-
viewed out of a total of 721 operations performed in the same
time period.
The results showed that the compliance with appropriate choice
of prophylactic antibiotic was 67% and the appropriate timing
was 45%. The compliance percentages have markedly de-
creased compared to the August 2010 review (87% and 83%
respectively), whereas re-dosing of prophylactic antibiotic, if re-
quired, has increased from 17% to 50%. It was observed that in 37
(51%) medical records, the section on Prophylactic Antibiotics
administration in the Pre-operative Verification Form was not
completed by the anesthesia resident.
The aim is to reach 100% compliance. The guidelines on appropri-
ate choice of prophylactic antibiotic have to be reviewed to
ensure compliance by all clinical specialties.
Lisa Sekilian, RN, BSN, MPH
Accreditation Compliance Officer
The hospital-wide Performance Improvement (PI) indicators
were revised and updated starting from January 2011, in order
to comply with the Joint Commission International (JCI) require-
ments. Similar to the 3rd edition standards, the JCI 4th edition
standards require monitoring a set of 11 clinical and 9 manage-
rial measures.
However, several requirements were intro-
duced to the new standards.
First, in addition to the above indicators, there is a need to
monitor at least 1 measure for each of the 6 International Pa-
tient Safety Goals (IPSG).
Second, out of the 11 clinical areas for monitoring, we have to
choose at least 5 indicators from the JCI Library of Clinical
Measures. Published by the JCI, this Library includes 36 indica-
tors related to 10 clinical areas. What is interesting in the Library
is that it clearly spells out the data collection guidelines, aiming
at standardizing data collection methods across organizations.
The Library will be the 1st step towards establishing international
benchmarks. A Library for the managerial measures will follow.
Third, the JCI now requires us to conduct at least 1 validation
study for each chosen measure (standards QPS.5 and QPS.5.1).
Data pertaining to the same period of time will be reviewed by
2 independent abstractors at different times. The 2nd measure-
ment will utilize the same measure definitions and data collec-
tion tools, but will cover only a random sample of the popula-
tion. The results will be compared; discrepancies, if any, will be
identified, and corrective actions taken.
For more information, check the list of the 2011 PI indicators
and the JCI Library of Measures.
Lina Mekawi, MS
Senior Data Analyst
Hospital-Wide Indicators 2011 & the JCI Library of Measures
Mohamed Mesto Registered Nurse ED Daad Farhat Embryologist-IVF Technician OB/GYN Iman Shuaitani Data Entry Clerk Hospital Admin. Maya al Masri Floor Clerk Neuro ICU The Big Prize winner was: Wael SaasouhWael Saasouh, MD from the Anesthesia Department. He received a 220$ worth gift while the other winners received various gifts.
http://staff.aub.edu.lb/~webaccrm/
AUBMC Policy and Procedure Manuals Available Online: https://his.aub.edu.lb/
Quality, Accreditation and Risk Management Program
In line with the AUBMC Performance Improvement PI Plan (QPS-MUL-002), the Quality, Accreditation and Risk Management Program (QARM) staff have been assigned to provide performance improvement support services in accordance with proper PI practices and to comply with the accreditation standards (Joint Commission and Ministry of Public Health). For this purpose, each AUBMC department/section (excluding the nursing services) has been assigned to an individual Quality Review Analyst / Coordinator with a clear set of objectives and guidelines.
The QARM staff have already initiated meetings with respective department heads/chairpersons to discuss performance im-provement activities in their respective departments. The idea of departmental performance improvement activity was wel-comed by most of the department heads/chairpersons and some good initiatives are reported in this article.
The Food Services Department has a challenging job ahead. With the introduction of new items in the menu, food quality, dis-play, variety, service, personnel and overall rating are areas that will be monitored through comment cards completed by the patients. Moreover, temperature monitoring of frozen and chilled items upon receiving from dealers and during storage will be recorded to ensure safety of food production. The Endoscopy Unit is in the process of selecting three indicators one of them is related to complications rate. The Internal Medicine, in coordination with Dr. Ali Taher, is working on a PI initiative related to compliance with VTE prophylaxis. A simpler form of the VTE prophylaxis will be prepared to boost compliance.
The Emergency Unit is doing tremendous effort to eliminate the causes of discrepancies between the preliminary radiology report and the final one. The discrepancies are being recorded and tabulated and will be analyzed by the QARM. Corrective measures will positively reflect on the patient safety in ED.
Other departments are also on the quality improvement path, and their news will be published in next coming issues.
Lisa Sekilian, RN, BSN, MPH Abdellatif Marini, MS Accreditation Compliance Officer Quality Review Analyst
