Keeping up with safety and quality trends is a vital albeit time-consuming task. Here you can find a regularly updated gathering of hot-button trends and initiatives that are influencing national healthcare. Each issue includes a synopsis as well as source links and other helpful media.
Table of Contents
CUSP Toolkit (AHRQ)
National Patient Safety Goals
Patient-Centered Medicine Label Standards and Best Practices
Quality Indicators™ Toolkit for Hospitals
Reducing Bloodstream Infections Through Universal Decolonization
NQF’s Serious Reportable Events and Safe Practices
Transitions of Care
The Agency for Healthcare Research and Quality offers a Comprehensive Unit-based Safety Program (CUSP) Toolkit to help doctors, nurses and other clinicians work together to successfully identify and solve issues that threaten the safety of their patients. It focuses on best practices with consideration of the science of safety, improved safety culture and an increased emphasis on teamwork. This modular toolkit was created for clinicians by clinicians and is customizable to meet individual unit needs. Teaching tools and resources include: facilitator notes, presentation slides and videos.
The program was used in implementing a nationwide patient safety initiative that decreased the number of central line-associated bloodstream infections (CLABSIs) in participating intensive care units by 40 percent. Clinicians in 1,100 adult intensive care units in 44 states participated in the project, titled ON THE CUSP: Stop BSI, over a 4-year period making the initiative, developed by a team at Johns Hopkins Medicine and funded by AHRQ, the largest of its kind to date. In an environment where one in 20 patients is affected by healthcare-associated infections, preliminary results indicating that this endeavor prevented 2,000 CLABSIs and saved more than 500 lives and $34 million in health care costs are extremely encouraging.
Watch the video below to learn more about ON THE CUSP from Peter J. Pronovost, M.D., Ph.D., senior vice president for patient safety and quality at JHM and leader of the CUSP development team.
It has been said that the greatest obstacle preventing advancement in patient safety is that we punish people for making mistakes. Conversely, the greatest opportunity for improvement lies in analyzing and learning from errors. Just Culture is about finding a balance between learning and accountability.
Just Culture creates an environment of mutual trust and fairness, whereby reporting and learning from errors and other safety hazards is encouraged and highly valued. It recognizes that competent professionals make mistakes but acknowledges the difference between human errors made within unreliable systems and intentional unsafe acts.
Healthcare is a high-risk industry. Adopting a Just Culture signifies an organization’s commitment to promoting a work environment in which all employees are willing to take responsibility and be forthcoming in regard to safety events and near misses in the interest of system improvement and safety.
The Joint Commission established the National Patient Safety Goals to help accredited organizations address some of the most challenging patient safety issues. The initial development and ongoing updates are overseen by the Patient Safety Advisory Group, an expert panel of physicians, nurses, risk managers and other professionals who have hands-on experience in a broad range of healthcare settings.
NPSGs are designed to stimulate improvement activities in key areas such as the accuracy of patient identification, safety when using high-alert medications and timely reporting of critical test results. NPSGs are reviewed and published each year to incorporate emerging patient safety issues and play a critical role in The Joint Commission’s overall efforts to improve healthcare.
The U.S. Pharmacopeial Convention (USP) provides a set of standards to be referenced in formatting labels for prescription medication containers with the aim of making instructions easier for patients to read and understand.
The Institute of Medicine reported in June 2012 that at least 77 million Americans have limited health literacy meaning they experience difficulty acquiring and comprehending basic health information and services. The USP believes that adoption of a universal practice for medication labeling will help combat medication misuse and reduce the number of adverse events resulting from misuse.
With new standards in place, label manufacturers, pharmacists and prescribers now have a roadmap for creating patient-centered labels that emphasize the information most critical for safe medicine usage. Sample prescription container labels, designed by the USP, illustrate the level of readability and explicitness that developers are trying to achieve by improving the way information and instructions are arranged and worded.
The video below features Dr. Thomas Reinders, Pharm.D., chair of the USP Nomenclature, Safety and Labeling Expert Committee discussing the impact that he believes these standards are going to have on patients.
The Agency for Healthcare Research and Quality is offering a free toolkit designed to guide hospitals in understanding and utilizing Patient Safety Indicators (PSIs) and Inpatient Quality Indicators (IQIs) to successfully improve care. The AHRQ Quality Indicators Toolkit for Hospitals uses administrative data to assess the care provided, identify areas in need of further investigation, and set priorities for performance improvement. It also offers tools aimed at a variety of audiences, including senior leaders, quality staff and multi-stakeholder improvement teams.
Working to reduce the risk of life-threatening, antibiotic-resistant infections including methicillin-resistant Staphylococcus aureus (MRSA), Hospital Corporation of America will mandate the practice of universal decolonization across nearly all of its facilities’ adult intensive care units by early 2013.
In a collaborative study conducted in 43 HCA-affiliate hospitals, physicians and researchers determined universal decolonization to be the best protocol for preventing infection from MRSA and other antibiotic-resistant bacteria in high risk patients. This simple but life-saving practice involves treating an entire patient population, bathing all patients using chlorhexidine antiseptic soap and swabbing their noses with mupirocin antibiotic ointment. In the study, universal decolonization reduced MRSA by 37% and reduced all central-line bloodstream infections by 44%.
Because the study, dubbed REDUCE MRSA, was implemented primarily in community hospitals, rather than in academic institutions, and was conducted by hospital personnel rather than by research staff, the study’s findings are anticipated to be applicable to nearly all hospitals nationwide.
To increase public accountability, transparency and systematic learning and improvement, the National Quality Forum created and endorsed a comprehensive list of Serious Reportable Events. The 29 events represent largely preventable, grave errors including injuries caused by care management and errors resulting from failure to follow standard care. NQF suggests these events be targeted for mandatory public reporting. To date, 15 states are using the SREs for reporting while another 12 are either using state-specific or AHRQ adverse events.
NQF’s Safe Practices for Better Healthcare is one of NQFs longest running endorsement projects and serves as a companion piece to SREs. The 34 endorsed safe practices are harmonized with safety initiatives from other national groups, such as CMS, AHRQ and The Joint Commission. NQF produces a manual that includes the latest safety evidence, implementation strategies and guidance for patient and family engagement.
Watch the video below to learn more about the steps NQF is taking to improve the quality of care in America.
TeamSTEPPS®, which stands for Team Strategies and Tools to Enhance Performance and Patient Safety, was jointly developed by the Department of Defense and Agency for Healthcare Research & Quality. This evidence-based teamwork system was created for healthcare professionals and offers a set of ready-to-use materials and a training curriculum rooted in 20 years of research. Ultimately, TeamSTEPPS® aims to transform culture through the formation of highly effective medical teams that optimize the use of information, people and resources to achieve the best outcomes for patients.
To learn more about this three-step process for developing a culture of teamwork, watch this video.
When patient transitions are rushed, communication is significantly compromised, and the responsibilities of patients and medical professionals often become unclear. By improving the processes through which patients are transitioned from one care setting to another, we can drastically impact patient safety and quality of care as well as outcomes and costs.
The National Transitions of Care Coalition provides an arena for healthcare experts and thought leaders nationwide to collaborate in identifying system gaps and defining solutions that will lead to smoother patient transitions and ultimately better outcomes. TOCC provides numerous tools and resources to patients, providers and policy makers interested in improving this aspect of our healthcare system.
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