Regulation, certification and accreditation - Impossible without pressure: the Regional Hospital of Locarno experience

Transcription

1 Regulation, certification and accreditation - Impossible without pressure: the Regional Hospital of Locarno experience International Congress Sécurité des patientes - avanti! Basel, November 30th, 2011

2 Contents Introduction EOC pilot project: JCI accreditation of the Regional Hospital of Locarno «La Carità» First results and lessons learned Risk for falls management: the «La Carità» Hospital experience JCI and drugs management Is coertion necessary to achieve a certification? The surgeon point of view

3 Introduction Angela Greco, Luca Merlini International Congress Sécurité des patientes - avanti! Basel, November 29th, 2011

4 Foreword A comparison across regulation, certification and accreditation Regulation/Licensure Certification Accreditation Goal Selection of Vendors Promotion of quality Option Mandatory Voluntary Impact Financial Prestige Level of Quality Adequate Adequate Dissemination All Many Management Region/Canton Several certification organizations Process Inspection/Assessment Assessment Contents Regulatory Organizationalmanagerial References Regulations Related Standards Promotion of quality and patient safety Voluntary Prestige Excellent Few Scientific Society Assessment and Consultation Technical Professional State of the art and scientific evidence

5 Our perspective... There is no magic formula for organizations engaged in quality management. What works well in a healthcare organization may not work at all in another. Each healthcare organization must create a quality management structure in its own image and likeness. reviewed by Berwick D. et al. Can quality management really work in healthcare? Quality Progress1992; 25 (4:25).

6 The questions we will try to answer Regulation, certification and accreditation: is it possible without pressure? External pressure? Internal pressure from whom? Hospital s managers? Project managers? Commitment within the project team?

7 EOC pilot project: JCI accreditation of the Regional Hospital of Locarno Luca Merlini, Angela Greco International Congress Sécurité des patientes - avanti! Basel, November 29th, 2011

8 The strengths of Joint Commission Accreditation The Joint Commission was founded almost 60 years ago It was established by and for the health care industry It evaluates the entire hospital as patient care involves complex interactions amongst all of the functions and processes of an organization It focuses on systems, rather than on individuals It drives ongoing improvement Standards concern structures, processes, and outcomes It allows for comparison across key issues it is at the forefront in the development of performance and outcome measures for healthcare organizations It uses consensus standards for the evaluation, that are continuously updated It engages healthcare professionals in defining the standards and in the evaluation process It uses the tracer methodology It has an international division

9 An integrated model Is it clear for everybody? JCI Any questions?

10 What are the contents? International standards (4 th Edition) International patient safety goals (IPSG) QPS Patient-Centered Standards (organizzati sulla base di quanto viene fatto direttamente o indirettamente per al paziente): Access to Care and Continuity of Care (ACC) Patient and Family Rights (PFR) Assesment of Patients (AOP) Care of Patients (COP) Anesthesia ans Surgical Care (ASC) Medication Management and Use (MMU) Patient and Family Education (PFE) MCI ACC IPSG AOP PFR PFE COP PCI Health Care Organisation Management Standards (sistematizzati sulla base di quanto viene fatto dalla struttura e dai suoi leaders per garantire e mantenere la qualità della cura attraverso una corretta organizzazione): Quality Improvement and Patient Safety (QPS) Prevention and Control of Infections (PCI) Governance, Leadership, and Direction (GLD) Facility Management and Safety (FMS) Staff Qualifications and Education (SQE) Management of Communication and Information (MCI) SQE MMU FMS ASC GLD

11 JCI Accreditation Process Time Line

12 JCI Accredited Hospital in the world Austria (1) Bahamas (1) Bangladesh (1) Belgium (1) Brazil (18) Chile (2) China (12) Colombia (2) Costa Rica (3) Czech Republic (4) Denmark (11) Ecuador (1) Egypt (3) Germany (5) Greece (1) India (16) Indonesia (4) Irleland (17) Israel (6) Italy (14) Japan (2) Jordan (9) Kuwait (2) Lebanon (2) Malaysia (7) Mexico (8) Nicaragua (1) Nigeria (1) Pakistan (1) Panama (2) Philippines (4) Portugal (4) Quatar (5) Russian Federation (1) Saudi Arabia (35) Singapore (14) South Korea (10) Spain (7) Switzerland (1) Taiwan (11) Thailand (15) Turkey (40) United Arab Emirates (35) Yemen (1)

13 Hospital of Locarno main figures 2009 figures 610 employees 170 bed capacity 85 milion costs (in CHF) admissions day care outpatients emergency room visits surgeries 7. 5 average hospital days 95 % average rate of beds occupation

14 The JCI project steps and timelines Fasi e attività STUDIO PRELIMINARE Tempo I sem.03 II sem.03 I sem.04 II sem.04 I sem.05 II sem.05 I sem.06 II sem.06 I sem.07 II sem.07 I sem.08 II sem.08 Scelta di un modello qualità di riferimento Assesment iniziale (pre-survey JCI) Gennaio 2004 Marzo 2004 CONCETTO DI MASSIMA Nuovo concetto qualità EOC (ODL ospedale pilota implementazione JCI) REALIZZAZIONE Creazione dei circoli qualità Analisi degli standard Individuazione dei possibili miglioramenti Monitoraggio interno sistematico Implementazione azioni di miglioramento 14 teams approx. 60 people involved 70% behaviors 25% documents 5% indicators Maggio 2005 Pre-survey JCI Survey finale per accreditamento JCI Marzo 2008 Maggio 2008 ANALISI DI FATTIBILITÀ: PROPOSTA DI UN "MODELLO QUALITÀ EOC"

15 Q Over 10 years of engagement in continuous quality improvement ( ) Board of Directors Empower ment team Culture of values Departmen tal Organizati on Iso 9001: 2000 Iso 14001: Quality Team Hospital Risk Manag. JCI mock survey Accred United agains t pain Qualy point First RCA and FMECA JCI Accredit ation Hospital as a service provider organizat ion Alignmen t RU Strategie s ITACA Strategy planning CPI Iso 17025: 1999 Unicef recogn ition Painless Hospital Project DocQ Patient Pathway s 4 TQ, CRCC, CIQ, Facility Safety Committ ee UNICEF reaccre ditation Vision Mission Values Staff Educatio n dept. Quality and internal communi cation dept. Internal audits Vision Mission Values H- Quality Standard Mission Vision Values (EOC) Exprix award JCI Indicato rs Projects IPSGs Human Resource Managem ent MBO Compete ncy Model MBO team Controllin g Standard EBM Fourchette verte Energy 2000 EFQM BSC Worklif e survey BSC EOC ( ) Energo Project Hildeb rand Partne rship Patient record review PRN Swot Analysis Health Promoting Hospital Project T

16 Why Locarno? Q JCI EFQM ISO DSS Quality Department T

17 Our first report card IPSG - International Patient Safety Goals ACC - Access to Care and Continuity of Care PFR - Patient and Family Rights AOP - Assessment of Patients COP - Care of Patients ASC - Anesthesia and Surgical Care MMU - Medication Management and Use PFE - Patient and Family Educations QPS - Quality Improvement and Patient Safety PCI - Prevention and Control of Infections GLD - Governance, Leadership, and Direction FMS - Facility Management and Safety Measurable Elements partially met; 15; 1.2% Measurable Elements not met; 1; 0.1% Measurable Elements met; 1198; 98.7% SQE - Staff Qualifications and Education MCI - Management of Communication and Information Measurable Elements met Measurable Elements partially met Measurable Elements not met % 20% 40% 60% 80% 100% Percentage of total measurable elements of each standards cluster 3 1

18 2nd report card: employees perception IPSG - International Patient Safety Goals ; 26% 14; 30% ACC - Access to Care and Continuity of Care 0 PFR - Patient and Family Rights AOP - Assessment of Patients ; 44% COP - Care of Patients Medical Doctors ASC - Anesthesia and Surgical Care Paramedics (nurses, tech-medical, dietitians, etc.) MMU - Medication Management and Use Administration (management, human resources, hospitality, maintenace etc.) PFE - Patient and Family Educations QPS - Quality Improvement and Patient Safety PCI - Prevention and Control of Infections GLD - Governance, Leadership, and Direction FMS - Facility Management and Safety SQE - Staff Qualifications and Education 0 MCI - Management of Communication and Information Not usefull Partially usefull 0% 20% 40% 60% 80% 100% Percentage of total answ erers (n. 47) Usefull

19 Our strategies to implement the project: Clear and precise goals Work method and clear standards for reference Third-party authority (JCI) to overcome the institutional selfregarding nature Incentive (the will to achieve JCI accreditation) Choice of charismatic individuals as part of the patient records review committee Persistent identification of new areas for improvement Ongoing staff education Communication strategy: poster campaign on hospital wards Reassessment of the evaluation tasks assigned to the various professionals in order to eliminate redundancies Adaptation and simplification of patient records Intensive supervision by senior physicians and head nurses

20 Some other keys to success EOC Quality Strategic Committee PDCA Method EOQUAL CQI Philosophy (Continous Quality Improvement) Quality Critical area Team Quality Medicine Team Quality Surgery Team Committee on infrastructure safety Committee on key quality data Hospital Quality and risk management Commitee + Quality Department Quality Woman-child Team Quality Facilities and operations Team Committee on Nutrition Committee on medical records review Committee on hygiene RF RGD

21 JCI project organization chart (3rd Edition of Standards)

22 Complicated easy vs Simple hard H A G B F C E D self-discipline generosity listening trust JCI Synergy and communication The whole is more than the sum of its parts (Aristotle)

23 Lessons learned (1) Resistance to change Overcome the suspicion about the system benefits Initial increased workload / commitment Stress of recent months The amount of information to be taken into consideration Training time The difficulty of being a "pioneer Need to review the documentation Modification of professional conduct

24 Lessons learned (2) Interdisciplinary work Provide disseminated leadership Self-analysis and setup of improvement plans Comparison with others (not self-referent) Quality suveryors Matches cantonal requirements Standard JCI EOC/TI/CH guidelines Learning from patients Manage risks and identify potential damage Discover hidden waste, dangers and inefficiencies Efficient resources allocation Data-based decision making Superivison of clinical area by the administrator

25 Fall risk management: the «La Carità» Hospital experience Chiara Canonica, Angela Greco, Giovanni Rabito International Congress Sécurité des patientes - avanti! Basel, November 29th, 2011

26 International Patient Safety Goals 6. Reduce the Risk of Patient Harm resulting from Fallsl How? Initial assessment for fall risk AOP.1.6 EM 4 Reassessment of patient harm when indicated by a change in condition, medications, etc. AOP.1.6 EM 5 Implementation of measures to reduce fall risk for those assessed to be at risk AOP.1.6 EM 6 SO WHAT ARE WE DOING?

27 INITIAL SITUATION - initial nursing assessment based on experience rather than objective data - reassessment? - information / education / prevention measures? - monitoring? - adverse event reporting?

28 from single thinking I know my job I am experienced to critical thinking definition of a screening tool / literature revision of policies / education professional integration Common goal Reduce the Risk of patient harm resulting from falls IPSG 6 /JCI

29 CURRENT SITUATION Initial nursing assessment: fall risk assessment (Schmid Fall Risk Assessment Tool) Dimensione Protocollo Punteggio Età anni 0 75 anni 1 Indipendente, deambulazione senza disturbi nell andatura 0 Mobilità Deambulazione o trasferimenti con assistenza o ausili 1 Deambulazione con andatura insicura senza assistenza 1 Impossibilitato nella deambulazione o nei trasferimenti 1 Indipendente 0 Evacuazione Necessita di assistenza per l evacuazione 1 Stato mentale Stato sensoriale Farmaci Incontinente 1 Vigile e orientato 0 Costantemente confuso 1 Periodicamente confuso 1 Nessun deficit 0 Deficit visivo e uditivo 1 Anticonvulsivi, Benzodiazepine, Antipertensivi, Diuretici, Antipsicotici, Antiparkinsoniani, Psicotropici 1 Nessuno dei precedenti farmaci 0 Punteggio totale If RISK SCORED 3: 1. Implement fall prevention protocol 2. Recommend P.T. consult to MD 3. Provide prevention education brochure to family and visitors (with prior consent)

30 Risk reduction measures: the fall prevention protocol

31 But. are all patients being assessed as defined in the policies we have written? Anamnesi infermieristica 100% % 80% % 5 60% 50% 40% % % 10% 0% Anno 2007 Anno 2008 Anno 2009 Anno 2010 Mobilizzazione - Screening rischio cadute Completo Incompleto Assente

32 ...what if a patient falls anyways?

33 Fall risk analysis using facility and equipment safety checklist Corrective actions

34 Reporting - Corrective actions and communication - Annual and six-monthly detailed analyses, comparison against goals, EOC benchmarking - Staff education and sensitization: once a year presentation about results and corrective actions G. Rabito, A. Greco / / Pag. 34

35 Conclusion example PDCA cycle applied to the patients risk for falls Action/reaction staff education/sensitizazion analysis of facility safety elements in inpatient rooms and bathrooms that may contribute to the fall event Planning Identification of goals and strategies to reduce the risk of falling (Annual plan for quality and patient safety) Check The quality indicators committee biannually evaluates the overall trend of results against planned goals Patient record review committee four-monthly evaluation Falls committee Implementation Assessment as part of patient history Adoption of preventive measures (I-SAN- 014) Systematic monitoring of fall events

36 JCI and drugs management Rita Monotti, Michela Pironi International Congress Sécurité des patientes - avanti! Basel, November 29th, 2011

37 Drugs management: AIMS Many aims to achieve regarding every step of the drug s process (HIGH RISK PROCESS): 85 standards MMU. For example: => safe concentrate electrolytes storage => safe drugs samples management => effective medications labelling after preparation => effective method for patient s identification before administration Many changes necessary to increase patient s security and be compliant to JCI standards One of them: INCREASE THE SECURITY in DRUGS PRESCRIPTION according to JCI requirements

38 Drugs prescription & Detailed JCI requirements: 1. ABOUT COMPLETE PRESCRIPTIONS (date, time, drug s name, dose, frequency, route of administration, doctor s signature, details for as required drugs) 2. ABOUT DRUGS PRESCRIPTION MODIFICATIONS 3. ABOUT THE DOUBLE CHECK OF EVERY NEW DRUG PRESCRIBED (allergy? interactions? drug appropriate? Drug necessary? Is the best dose, frequency, route of administration for the patient?...)

39 Initial situation at Locarno - many prescription papers - transcription on nurse s documents Hospital NEED for a cultural change!

40 First step Written policy about drugs prescription requirements 1. Definition of which elements are necessary to prescribe properly 2. Definition of which elements need to be controlled during the double check but many doctors objections, especially about the prescriptions double check ( who will do it? No time do it Is it necessary? Senior doctor double checked by a junior doctor? )

41 Some data from the literature Errors in the medication process: frequency, type and potential clnical consequences M. Lisby et al Int.J. of Quality in Health Care 2005; Vol 17, N 1:15-22 Drugs related errors: 63/133 (47%) patients : drugs related problems - ORDERING: 39% - TRANSCRIPTION: 56% Serious/ fatal clinical consequence 20% 23% Significant clinical consequence 40% 41% High incidence of medication documentation errors in a Swiss university hospital due to the handwritten prescription process Hartel et al, BMC Health Services Research 2011 Aug :199 Drugs related errors: 65/165 patients (1934 prescribed agents) prescription errors: 37% transcription errors: 53%

42 Second step Creation of a guided prescription paper Implementation: difficult! Compliance to improve

43 Third step Check & improve the compliance 1. Pocket guide about drugs prescription & double check requirements distributed among Doctors (Compromise: self control admitted!) 2. Audits, tracers & monitoring of clinical records (to test completeness) 3. Qualypoint promotion (spontaneous notification of ADEs & drugs related errors to the quality service) => Analysis to prevent new errors

44 Medical records general completeness

45 Drugs related problems analysis 145 ADE/drugs related problems spontaneously notified in 15 months ( ) 4.8% led to a specific patient s treatment! Survey and management of non conformities drugs related, M.Pironi, A.Greco, D.Caronzolo, B. Waldispuehl - Poster GSASA Non conformities related to drugs prescription, transcription, administration ( ) 16% Transcription errors 43% Not written medical orders 23% 18% Incomplete drugs prescription Drugs prescribed in allergic patients

46 Current situation at Locarno Hospital Some prescriptions done in a guided paper ; well defined prescriptions requirements, but different prescriptions papers still used More sensitivity to spontaneously report ADE or drugs related errors & more sensitivity for new drugs prescription double check Transcription still present (no drug chart implemented) Preparation process improvement Prescription done on a white paper Many different prescriptions papers Transcription in a nurse document, used for drugs administration No double check of new drugs prescribed Future: Informatic prescription Test of a drug chart (shared document Dr/nurses) to reduce transcriptions and decrease the number of prescription papers (implemented only for Intensive care)

47 Conclusion JCI: input to review the drugs related process and increase its security; it requires of a big cultural change (energy & time consuming) For that reason necessity to have: - clear objectives - CLARITY; COHERENCE & COHESION AMONG MEDICAL AND NON MEDICAL LEADERSHIP TO CREATE AN INTERNAL PRESSURE - Lobbying pressure by Pharmacists missing

48 Is coertion necessary to achieve a certification? The surgeon point of view Stéphane Schlunke International Congress Sécurité des patientes - avanti! Basel, November 29th, 2011

49 Certification & Coertion My objective: share the experience of certification in the eyes of a (egocentric) surgeon

50 Coertion & Certification

51 Coertion No Evidence of higher quality by certification Seek of evidence drives doctors daily work Doctors are smart and passion driven workers

52 Coertion Yes Doctors are human... who fear changes and loss of «power» Doctors are «free» thinkers... control steps down their «independance» I m a doctor! I know what I m doing!

53 Certification & Fear Fear brings automatic reactions... from the Ego Automatism... «this is the way we do it... we always did it that way» Automatism...resistance to the unknown

54 EGO & Surgeons How can you consciously inflict a wound to another human being if you are not sure that YOU are right? that you excactly know what you are doing? As a matter of fact there is still little evidence in surgery... surgery remained a kind of «art»

55 Surgeons are artist s The talent of improvisation is of great help for a surgeon (and his patient) during difficult and rarely seen clinical situations Controlling as from measurements (certification) are likely to cut the «wing s of inspiration»...

56 Coertion & Certification

57 Coertion & Certification

58 Coertion & Certification WAY OUT: there is a noble goal in certification if you really measure (certify) what you are doing... then you really know what you are doing! more control = more quality and patient safety

59 Thank you!