RN, BS, CPHQ

Presented By:Trudi Lovinski RN, BS, CPHQ

Quality / Risk DirectorCentennial Medical Center

Objectives

1. Identify the changes and challenges for 2009-2110

2. Share methodologies for compliance and measurement

3.Demonstrate standardization of processes to reduce variation

Our Facility Still Growing - 635 Patient Beds

Hospital

QUALITY STANDARDS

Accreditation

Joint Commission

OIG State Dept of Health

Licensure

CMS

Medicare ProgramTermination Recommended to OIG

State Survey Agency of Enforcement

Fede

ral L

aws

&

Con

dition

s of

Part

icip

atio

nC

ontr

act

Licensure Regulations & State Laws

=

Board of Medical Licensure

Hospital

=Monetary Penalties

QIO

Statement/Scope of Work

Quality Sanctions *Immediate Jeopardy*Serious Substantial *Gross & Flagrant *Physicians *Hospitals

Civil Monetary Penalties

Office ofCivil Rights/HIPAA

CLIA Lab/ Pathology

Official Medicare Program Termination

CAP (Lab/ Pathology)

Public Notice

Medicare Payment Stopped

FBI/AG/DOJ

HCA © Quality Standards

NATIONAL PATIENT SAFETY GOAL’S (NPSG) WERE INTRODUCED IN 2005

6 NEW ADDITIONS TO NPSG’S – INTRODUCED MID -2008

• Phase in goals for Infection Control (IC) – full implementation in 2010• Full implementation for Anticoagulation Therapy goals in 2010• Full implementation requiring improved recognition of changes in a

patient’s condition in 2010

NO NEW NATIONAL PATIENT SAFETY GOALS FOR 2010!!!!!!!!!!!

CONCERNS:• Superficial fixes were put into place ( policies, forms) which caused

multiple issues ( unable to redesign process, overwhelmed staff)

• Today NPSG’s are built off current collaboratives for improvement rather than from patient safety risk reduction strategies.

• Previous NPSG’s were the results of reported sentinel events

• Refocus• Simplify processes• Patient Safety as the #1 priority• Make recommendations to TJC through the standards

interpretation process• One size does not fit all. The process needs to match the

practice setting• Challenges: NPSG 8 – Medication Reconciliation 1 out of 5 hospitals was non-compliant Series of forms and numerous documentation

requirements Result: Joint Commission will evaluate and refine expectations

• Scoring of NPSG 8 has been modified, retroactive as of 1/1/2009 - Findings will not contribute to the accreditation decision - Findings will not appear on the accreditation report - Surveyors will continue to evaluate the organization’s Med Rec

process - Improved NPSG 8 to be implemented by the field in 2010

Patient Identifiers

• CMC utilizes two main identifiers

• Patient Name• Patient Date of Birth

• Other identifiers used when the patient /family members are unable to provide verbal confirmation of patient name, and date of birth are, but not limited to:

• A 2 person verification at the bedside utilizing the MR number on the arm band

• E-Mar bar coding system

Patient Identifiers

•Labeling of all specimens collected will occur at the bedside

• All transfusion products are verified at the bedside by the following processes:

• 2 qualified licensed nurses, in which one must be the transfusionist.

• Automated identification technology consisting of a Bar Coding system when only 1 licensed personnel is available.

Verbal/Telephone Orders

• Ineffective communication is the most frequent cause of errors related to patient care. Improving the effectiveness of communication that is timely, accurate, complete, unambiguous, and understood by the receiver reduces potential errors and increases patient safety.

• Verbal/Telephone orders are discouraged and should be limited to urgent situations only, due to the high possibility of communication errors involving , but not limited to: • Medications• Treatments• Procedures

Standardized List of Abbreviations, Acronyms, Symbols

• Develop a list that co-insides with Joint Commission list of dangerous abbreviations, acronyms, symbols, and dose designations that will not be utilized in any section of the patient’s medical record.

• CMC has initiated several different types of reminders to help prevent the use of dangerous abbreviations, acronyms, symbols and dose designations, these reminders include but is not limited to:

• Posters containing the DO NOT USE list on each unit of the facility

• Pathways/Standing Orders that have been approved through the Forms Committee to ensure that none of the DO NOT USE abbreviations is used in an order.

• Lists of non-approved abbreviations placed in front of the Physician’s Orders section in each chart

• Audits to help identify problem areas and provide assistance with improvement initiatives.

Critical Values

Critical Values are test results that are beyond the normal variation with a high probability of a significant increase in morbidity and/or mortality in the near future

The term “critical test results” applies to all diagnostic tests including imaging studies, electrocardiograms, laboratory tests and other diagnostic tests and studies (JCAHO 10/27/03).

Quality Management measures, assesses, and monitors the timeliness of reporting and receipt of critical tests/results by the responsible licensed staff.

Percentages calculated based on 1 month total number of critical values called from different departments. N=664

Hematology24.1%

Chemistry, 28%Radiology,

4.2%Microbiology7.

8%

Transplant Drug Therapy

3.6%

Therapeutic Drugs 9.6%7

Respiratory ABG’s 14.6%

Transplant Drug Therapy

3%

Cord Blood PH 1%

Percentage of Critical Values Proportion to Different

Departments

Hematology

Chemistry

Radiology

Microbiology

Coagulation

Theraputic Drugs

Respiratory ABG's

Transplant Drug Therapy

Cord Blood PH

Critical Values

• Only licensed clinical staff can receive critical value calls from procedural areas.

• Critical values are to be documented only in the Critical Values intervention screen on the O.E charting screen (exception of NICU due to Neonatologist on staff 7/24).

• Nurse receiving critical value calls from procedure areas must provide their name & title, and read back the value to the caller.

• Nurse documents • Caller Name, location & time result called• Unit patient is in (CCU, 4T, 5T, )• Critical Value & Read Back Performed• Nurse who received results & documenting• Time Physician Called• Time Physician Returned Call• Repeat Back from Physician of value• Any new orders or if patient is on a protocol

Hand-Off Communication

• There are many different types of Hand-Off Communication that are utilized in our facility. These include by is not limited to:

• Face to Face• Taped report with off going/on coming staff to allow for clarification of any questions• Telephone report (i.e. PACU to Nursing unit, nursing to utilize format on hand-off form to ensure all pertinent information is conveyed• Faxed report with a follow up phone

report (i.e. Report from NH, MD office,

Hospitals) • Pre-Op (Pre-Procedure) check list

Hand-Off Communication

• Components required to occur during Hand-Off Communication include, but not limited to:• Most current and accurate information

regarding:• Treatments• Labs drawn/orders requested• Results from tests• Patient’s Condition• LOC (Level of Consciousness)• Any recent or anticipated changes• Medications ( Last dose given , next

dose due)• Use of SBAR

• Situation• Background• Assessment• Recommendation

Hand-Off Communication

• Components required to occur during Hand-Off Communication include, but not limited to:

• Interruptions during Hand-Off are limited

• Nursing call system phones are turned off

• Incoming calls are received by CN (charge nurse)

• Call lights are answered by staff

members who have completed hand-off on their patients.

• On coming nurses are introduced to

patients by off going nurses to ensure no questions remain .

• Check of patient lines, tubes, LOC, pending tests, dressings,

and drains are completed at this time.

Look Alike / Sound Alike Meds

• Actions that are taken by Pharmacy to prevent medications errors

• include, but not limited to:• Quarterly review of new medications against the list of look

alike/sound alike medications in the pharmacy• Use of RED STICKERS placed on packaging indicating Look

alike/Sound alike• Storage of medications that are look alike/sound alike are

placed in separate sections of the pharmacy as well as in the

Accu-Dose or Pyxis systems• Utilization of TALL MAN lettering.

• Pharmacy will use capital letters on the labels to indicate the difference between the two meds.

Look Alike / Sound Alike Meds

• Pharmacy has composed the following list of Look alike/Sound alike medications.

• This list is updated annually, and as needed, when a change has been made with suppliers and when new shipments of medication enter the facility

• Each unit receives a copy of these medications annually, or when additional medications have been identified. This list is available on our Intranet.

High Risk Medications

• Unit-Specific Hemodynamic/High- Risk IV Medications, have been identified with limitations noted, based upon location, monitoring needs, and required competencies. High-risk medications can be given in:

• MSICU• ICU• CCU• Oncology• 5 / 8 Tower units• 6 / 7 Tower units• NICU• 3 Women's• Labor & Delivery, High Risk OB• OB Assessment Center • Rapid Response Team

Labeling Medication

Label all medication containers (for example, syringes, medicine cups, basins), or other solutions on and off the sterile field.

• Unlabeled medications or medication containers cannot be identified accurately • Labeled medications and medication containers reduce the risk of potentially serious medication errors

Labeling Medication• Verify :

• Correct name of the medication • Correct strength of medication• Correct dosage• Expiration date / time if not used in 24 hours

• All medication labels are verified by 2 qualified nurses, verbally and visually, when the nurse drawing up the medication is not the person that will be administering the medication

• Do not draw up multiple medications at the same time. Doing so increases the possibility of errors

Labeling Medication

• Original containers of medications transferred to another container must remain available for reference during any pre-operative , operative, or post operative period, until the conclusion of the procedure.

• All labeled containers are disposed of at the conclusion of the procedure

Container set next to syringe

Anticoagulant Therapy

• Standardized practices for anticoagulation

therapy have been initiated for our patients receiving heparin, low

molecular weight heparin, (arixtra, lovenox)

and warfarin.

• Upon admission a DVT/VTE evaluation,

(risk factors) is performed by the nursing staff.

• Once the evaluation has been completed a DVT/VTE order sheet is printed

for the physician to address risk factors by checking the protocol he/she wishes to be activated.

Anticoagulant Therapy

• DVT/VTE order sheets are scanned to pharmacy (will monitor patients MEDS/INR results)

• Dietary Services receives a print off, every morning, (food/drug interaction report) of patients who are on anticoagulation therapy • Education provided by multi-disciplines (nursing, dietary, physician, pharmacist)

Anticoagulant

Room #

Pt Nam

e

Do

se

Anticoagulant Therapy

• Protocols are initiated based upon Nursing assessment and Physician orders

• Once protocols are initiated, each of the following occurs:

• Base line PT/INR/PTT obtained• Daily PT/INR• Adjustments on dosing according to lab results • Dietary education regarding food interactions

• Nursing education regarding • Bleeding precautions• Avoiding straight razors, disposable • razors• Use of electric razors • Need for frequent blood test• Activity• Use of sequential compression• device, TED’s, or both

Anticoagulant Therapy

• Nursing Processes Help Reduce Errors

• Reducing possible errors related to wrong dose has been addressed by implementing:

• Use of Alairs IV pump system for drips• Utilizing Pharm D’s on units for correct dosage calculation and documentation• Protocols indicating required lab testing with adjustments to medication dosage according to results

• Ability to add interventions to the care plan and customize the Goal/Problem to include daily testing, and dose adjustments according

to test results

Anticoagulant Therapy

• Quality Management will be monitoring the use of:

• Completion of DVT/VTE forms on admission• Completion of DVT/VTE assessment every shift• Baseline PT/INR completed prior to administration

of anticoagulants• Daily PT/INR ordered while on anticoagulants• Dietary Consults completed in timely manner• Patient education documented by all disciplines

under the Patient Education Intervention screen

• Documentation regarding use of Krames/Clinical

Pharmacology sites for discharge• Documentation of patient’s understanding of

importance of follow up care/test/dosage and precautions.

• Nurse Managers will receive a copy of audit findings.

• Audit results will be posted on the Leadership Dashboard

Hand Hygiene

• Surgical Hand Antisepsis• Surgical hand scrubs may utilize either an antiseptic handwash or an antiseptic hand rub.• Antiseptic handwash requires a 3 – 5 minute scrub• Refer to Surgery Scrub Policy.

If you could seeThe germs, you’d Wash your hands!!

Flu

ColdsMRSAStaff

Calstat

When hands are not visibly dirty

Surgical Scrub

U se for assisting with SurgeryInvasive ProcedureRequires 3-5 minute Scrub(“traditional scrub”)

Hand Hygiene

* It is the responsibility of the Manager and/or Director to enforce the policy regarding artificial nails for applicable personnel.* Artificial nails are not permitted in direct patient care areas and

central sterile processing.* Nail polish may be worn as long as the polish is in good condition (i.e. not chipped or cracked).

Artificial Nails Unaccepted

Chipped UnacceptedNo Chips Acceptable

MDRO’s

• Lab notifies the nursing unit, and IC of MDRO.

• Current design addresses the 4 organisms cited in HCA’s HAI

Initiative:– MRSA– VRE– VRSA– Acinetobacter

• Ability to address C-Diff is currently being developed by Corporate

• ICP screens features color-coded cues

• ICP can run Tracker continuously on second session of Meditech

• Gemms• Classic

MDRO’s

• Available Standardized Reports:• Patients on Transmission Based Precautions• Current Census of MDRO patients with detailed MRI data and

status of MRI data• Patients with Refusal• Various reports to be used as implementation tools• MRSA and VRE Surveillance Screens by date

• Excel download format

Central Line Associated Infections

• 90% of all CR-BSI’s are associated with Central Venous Access Devices (CVAD’s)• CVAD

• Defined as a central venous catheter with its tip in the superior vena cava just above the right atrium• CVAD’s may be a non-tunneled catheter, tunneled catheter, or an implanted port• Examples (not all-inclusive)

• Non-tunneled catheters: subclavian lines, jugular lines, PICC’s, femoral lines for

hemodialysis• Tunneled catheters: Groshong®, Hohn®, and Hickman® type catheters

Central Line Associated Infections

• Education: Learn about CR-BSI’s• Hand Hygiene• Asepsis• Maximal Barrier Precautions• 2% chlorhexidine based product (i.e.Chloraprep™) for skin

asepsis• Optimal Insertion Site• Daily Review of Line Necessity

Insertion Maintenance Removal

Central Line Associated Infections

FOR THE PHYSICIAN: Hand hygiene Sterile technique

Barriers: Non-sterile cap and mask

All hair should be under cap Mask should thoroughly cover nose and mouth Sterile gown and gloves

FOR THE PERSON ASSISTING:Hand hygieneAseptic techniqueMask

FOR THE PATIENT: Cover patient’s head and body with sterile drape

Central Line Assoc. Bacteremia Insertion Site Preparation

• Disinfect clean skin

• 2% chlorhexidine (i.e. ChloraPrep®) is the preferred skin prep agent and considered best practice (If allergic to chlorhexidine, use povidone-iodine)

• Do not use organic solvents (i.e. acetone) on the skin before insertion of catheters or during dressing changes

If hair removal is necessary to visualize the site or secure the dressing, use clippers or scissors. Do NOT shave the area.

Sterile transparent or sterile gauze may be used as a dressing

Do not use topical antibiotic ointment on insertion sites (exception may be hemodialysis catheter)

Protect the central line and site from becoming wet when showering

(i.e. plastic wrap, parafilm)

Central Line Assoc. Bacteremia

Preventing Surgical Site Infections

• The addition of stamping the patients chart with:

• Surgery End Time• Last antibiotic give• Next dose due at

• Utilization of flyers posted throughout our holding, OR suites, and PACU regarding which types of antibiotics are appropriate for which types/category of surgery has helped increase the compliance rate for preventing surgical site infections.

• Use of appropriate hair removal documented with pop up screens to ensure correct documentation and reminders that shaving/razors are not acceptable.

Medication Reconciliation

• Information required during documentation includes:• Sources used for this Documentation• Local Pharmacy used. (Look in library for list)• Clarification needed for any medication• Home Medication disposition.

• If any area of the home medication list requiredIf any area of the home medication list required•additional information regardingadditional information regarding

•Name of drugName of drug•DoseDose•RouteRoute•FrequencyFrequency•Last Dose TakenLast Dose Taken•Place a “Y” in the box for Clarification neededPlace a “Y” in the box for Clarification needed

Medication Reconciliation

• Admission Med Rec Form printed and Admission Med Rec Form printed and placedplaced

on chart under order section foron chart under order section for

physician/pharmacist to address and sign.physician/pharmacist to address and sign.

• Nursing may complete Admission Med RecNursing may complete Admission Med Rec

only by speaking with the physician, placing only by speaking with the physician, placing a a

check mark by each medication to continue check mark by each medication to continue

or do not take and sign V/O (RB) or do not take and sign V/O (RB)

Dr. Something/Nurse RNDr. Something/Nurse RN

. Physician to . Physician to counter sign V/O within counter sign V/O within 4848..hourshours,,

& includes & includes Time, DateTime, Date order was order was countersignedcountersigned

Medication Reconciliation• Transfer Med Rec must be completed on all

patients transferring from one unit to another, and to another facility.

• A Physician, Pharmacist, or Nurse can complete the transfer form. Note if the nurse is completing the form, she/he must obtain orders from the physician and sign the form as a V/O (RB) Dr. Someone/Nurse RN/LPN.

• When transferring a patient to a nursing home, make a copy of the transfer med rec and place in the chart. Original copy is to be sent with the patient’s information to the other facility.

Medication Reconciliation

• Modified Medication Reconciliation will occur in out

patient areas where no new long term/or changes to

long term medications will be prescribed to the patient. • Areas in our facility include, but not limited to:

• Endoscopy• Imaging/Specials• Emergency Room• Cardiac Cath Lab• Non-Invasive Cardiology• Same Day Surgery

• In these areas an Admission med rec list must be

obtained to ensure no reactions will occur with medications being used for the procedure.

• When the patient is discharged, the discharge med

rec form is completed with only the new short term medications listed, (ie. Antibiotics, pain meds). Remember if any change is made to long term home medications, a complete discharge med rec must be completed.

Medication Reconciliation• Once the discharge med rec form has been

completed, nursing enters the medications into the system on the discharge instruction sheet and prints out a patient discharge med rec form. The patient’s family is instructed on new medications, use , side effects and home meds to be continued. A signed copy is placed in the chart ( Provide education sheets from Krames on Demand

or Clinical Pharmacy.

• If the physician has left scripts, list the scripts on last page of the discharge med rec form. Simply indicate on lines provided : Scripts by Dr. Someone Lasix 10 mg 1 by mouth daily Keflex 500mg 1 every 6 hours till gone

Scripts by Dr. SomeoneLasix 10 mg 1 by mouth dailyKeflex 500mg 1 every 6 hours till gone G. Cotton RN

Rapid Response Team

• The rapid response team consist of:• Designated critical care nurses• Designated respiratory therapists

• Designated staff will be available 7/24 365 days a year

• Rapid response team members make periodic rounds on each

unit during his/her 12 hour shift in non-ICU areas

Rapid Response Team

• Response time for Rapid Response Team is:

• 5 minutes from the time the team was activated

• In the event that the team is unavailable due to a previous call, the team will call and activate the second responder on duty

• The rapid response team utilizes interventions per standing treatment protocols

• SBAR will be utilized to communicate with the attending physician results of the assessment

• The rapid response team will continue to stay with the patient until he/she is stabilized or assist with the transfer to a higher level of care.

Rapid Response Team

Continuum of Care – 03-13-09Early Warning Systems and Code Blue Events

IHI Q107

Q207

Q307

Q407

Q1

08

Q2

08

Q3

08

Q4

08

RRT - # time RRT deployed

91 119 179  233 298 295 265 235

RRT - Codes/1000 discharges

9.91 7.19 7.46  6.00 10.45 8.04 10 15.07

RRT - % codes occurring outside ICU

25.37 23.91 20.34 15.69 22.22 15.79 12.67 19.81

RRT October 1, 2006 – December 31, 2008 (1793)

Rapid Response Team

Mortality Rate

25.41

UCL

15.56

CL

5.71

LCL

4.20

9.20

14.20

19.20

24.20

29.20

Jan06

Mar May Jul Sep Nov Jan07

Mar May Jul Sep Nov Jan08

Mar May Jul Sep Nov

Month

Mo

rta

lity

Ra

te

Number of Inpatient Deaths / Number of Inpatient Discharges X 1000

Posters Placed in every Patient room

Our 3 P’s

Questions ?????

Thank you for attendingTrudi