Maryland Association for Healthcare Quality

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1 Maryland Association for Healthcare Quality Summer 2013, Issue 49 In This Issue President s Message CPHQ Review Course Becoming a High Reliability Organization From NAHQ E- News Did You Know Open Board 2013 MAHQ Board of Directors Roster Dear MAHQ Members, PRESIDENT S MESSAGE Now that summer is ending and fall approaches, it is the perfect time to become recognized as a healthcare quality professional. The Maryland Association for Healthcare Quality (MAHQ) is proud to announce that Susan Mellott, PhD RN CPHQ FNAHQ, will be returning to teach the CPHQ review course September This is the second time Dr. Mellott has taught the CPHQ review course for the MAHQ. She is a fantastic speaker who received high praises on her evaluations from her class participants. We are proud to announce that with her preparation, MAHQ had the largest number of students take and PASS the exam. We look forward to seeing you in September. Sincerely, Laura T. Schwartze RN-BC MS CPHQ HACP 2013 MAHQ President CPHQ Review Course When Thursday, September 19, :00 AM - Friday, September 20, :00 PM Eastern Time Where CPHQ Review Martin L. Doordan Health Sciences Inst Anne Arundel Medical Center 2000 Medical Parkway Annapolis, Maryland USA Attire Business Attire - 1 -

2 Fees View Event Fees View Event Summary View Event Agenda Click here to register. (Registration ends on September 13, 2013) Becoming a High Reliability Organization The journey towards becoming a high reliability organization (HRO) focuses on improving reliability through better process design, building a culture of reliability and leveraging human factors by creating intuitive designs that help people do the right thing. An organization s drive to become an HRO originates with safety. HRO focusing on several principles of reliability science: Designing reliable, standardized systems that support staff decisions, opportunities for feedback, ongoing learning and change Learning to be more mindful of decisions and actions using HRO theory (see below) Improving situational awareness the concept of reliably identifying at-risk patients, lessening their risk and escalating risks until the patient is safe Managing by prediction and having robust plans in place for the expected and the unexpected Looking at human factors how we relate to the world around us and how learning more about how we work and interact, and designing systems that take human factors into account, can help us better keep patients, families, employees and visitors safe The theory of high reliability has come to healthcare from naval aviation and the nuclear power industry. The following are five key characteristics of an HRO: 1. Preoccupation with Failure Everyone is focused on errors and near-misses, learning from them and figuring out how to prevent them from happening again. Attention to detail is crucial. Finding and fixing problems is everyone s responsibility and is encouraged and supported by leadership. 2. Reluctance to Simplify Interpretations Requires constantly asking the why question and inviting others with diverse experience to express their opinions. The belief is that the more you re immersed in something, the harder it is for you to objectively observe and question things that need questioning. Leverage new thinking to get the right answer! 3. Sensitivity to Operations (an HRO Distinguishing Characteristic) - 2 -

3 An ongoing concern with the unexpected. Hallmark actions include closing loopholes in processes where there is potential for patient harm, maintaining situational awareness, developing teams that speak up and paying attention to the frontline which in hospitals are primarily nurses, patient care attendants, techs and support staff. 4. Commitment to Resilience The concept that things will go wrong that we can t predict; mistakes will be made, and we will get into trouble. But we will quickly identify issues and have structures in place so we can immediately respond and minimize the harm. Errors won t disable us. 5. Deference to Expertise Finding and using experts for the given problem in the given time. More specifically, it means recognizing that those closest to the frontline are the experts and empowering them to make decisions when a critical issue arises; results in quicker mitigation of harm. In HROs, senior leaders are conducting frequent walk-rounds to reinforce safety behaviors and find and fix critical safety issues. They re also meeting in daily organizational safety briefs where they look back to learn from failures and look forward to predict and lessen risk or harm. Frontline leaders (for example, unit charge nurses) are rounding with staff every day, giving 5:1 positive to negative feedback, conducting daily huddles and modeling the expected safety behaviors. HRO leaders manage by anticipation and prediction rather than reaction. Frontline leaders are focused on predicting events in the next 24 hours and making real-time adjustments to keep patients, families, employees and visitors safe. A High Reliability Organization (HRO) is an organization that succeeds in avoiding catastrophes (patient harm) in an environment where normal accidents can be expected due to risk factors and complexity. Submitted by: Laura T. Schwartze RN-BC MS CPHQ HACP 2013 MAHQ President FROM NAHQ E-News The Joint Commission Q&A - 3 -

4 Question: What is The Joint Commission doing to improve the safety of health information technology? Answer: In July, The Joint Commission announced that it had received a sole source contract from the federal Office of the National Coordinator for Health Information Technology (ONC) to address one of the key recommendations made in the Institute of Medicine s report Health IT and Patient Safety: Building Safer Systems for Better Care. The report called for an independent entity to help identify unsafe health information technology (IT) conditions that have been associated with serious patient safety events, develop a process for preventing health IT-related adverse events, and educate the healthcare field and others about this work. The primary objective of the contract is to establish a credible and meaningful process that can be used to identify, understand, disseminate, and eventually help prevent health IT-related sentinel events that may cause serious or fatal harm to patients. The results of the work will inform ONC s Health IT Patient Safety Action and Surveillance Plan to use health IT to make care safer and continuously improve the safety of health IT. Health IT devices include hardware or software used to electronically create, maintain, analyze, store, or receive information to aid in the diagnosis, cure, mitigation, treatment, or prevention of disease. The definition excludes integral parts of implantable devices and medical equipment. As a component of its accreditation services, The Joint Commission s Office of Quality Monitoring (OQM) regularly receives reports of sentinel events, including health ITrelated sentinel events, from accredited organizations. The OQM staff routinely works with organizations to review their root cause analyses and aggregates data to increase public knowledge about sentinel events, their causes, and strategies for prevention. To accomplish the goals of the contract, The Joint Commission will enhance the use of its de-identified data warehouse of the Sentinel Event Database, and its associated reporting process, as permitted by The Joint Commission s contract with accredited healthcare organizations. Only the de-identified data warehouse will be used to fulfill the terms of the contract and no identifiable data will be shared or even accessed at any point. The de-identification of the data will involve removing any identifiable reference to the practitioner, staff, organization, and patient (under HIPAA standards). Patient Safety Organization (PSO) Q&A Barbara G. Rebold, MS BSN RN CPHQ, director of operations, ECRI Institute PSO Question: How do we develop a patient safety evaluation system (PSES)? Answer: Don t reinvent the wheel! As mentioned in last month s PSO Q&A, The Affordable Care Act (ACA) mandates participation in a PSO for hospitals with more than 50 beds to contract with Health Insurance Marketplaces (also known as health insurance exchanges). For providers to be able to meet the ACA requirement, they must create a PSES through which the organization collects eligible patient safety work product with the intent of providing it to a PSO

5 The most effective PSES will likely draw from your existing patient safety, quality, and improvement activities and staffing. A PSES is a defined space that becomes the protected legal environment for collecting, managing, and analyzing information for reporting to or by a PSO. Within the PSES, providers may candidly consider and analyze quality and safety information with the assurance that such activities are receiving the protections afforded by the Patient Safety and Quality Improvement Act. It may help to approach the work of establishing your PSES by breaking it down into the following four steps: Understand the terminology and concepts related to your PSES. Before engaging with a PSO or developing a PSES, it is important that you become familiar with the related legislation and terminology. ECRI has some resources. Define Your PSES. Take stock of what you re doing already to improve patient safety and quality of care, and then determine whether your existing systems and processes can be included in or serve as your PSES. Implement your PSES. Implement the PSES policies, procedures, and staff support you have defined. In order to apply the federal privilege and confidentiality protections granted by the Patient Safety Act, you will have to be able to substantiate that your patient safety information is appropriately and consistently managed within the boundary of your PSES. Manage and evaluate your PSES. Periodically review your PSES to determine whether it includes the right information staff members are following policies and procedures and working within the PSES as you intended you are submitting patient safety work product to your selected PSO and are receiving useful analysis and feedback from that PSO. By taking some logical, incremental steps, you re likely to find that an effective, successful, and compliant PSES is well within your reach! NGC Announces Revised Criteria for Inclusion of Clinical Practice Guidelines The National Guideline Clearinghouse (NGC), administered by the Agency for Healthcare Research and Quality (AHRQ), is revising its inclusion criteria for clinical practice guidelines to keep them current with advances in the field. Clinical practice guidelines include recommendations intended to optimize patient care based on a systematic review of evidence and an assessment of the benefits and harms of alternative care options. Beginning June 2014, NGC will start using new criteria that reflect the Institute of Medicine s definition of a clinical practice guideline provided in its 2011 standards

6 setting publication Clinical Practice Guidelines We Can Trust. The two main changes to the NGC inclusion criteria are that the guideline be based on a systematic review of the evidence, conducted through a literature review that summarizes evidence by identifying, selecting, assessing, and synthesizing the findings of similar but separate studies contains an assessment of the benefits and harms of the recommended care and alternative care options. The updated criteria will result in a greater proportion of higher-quality guidelines available at NGC, thereby helping improve care by giving clinicians evidenced-based, trustworthy information that they need to make decisions with their patients. For more information on NGC s revised criteria and its mission, visit To compare clinical practice guidelines and other related information, visit Aggressive Interventions Can Reduce Inpatient C. diff Infections A comprehensive infection control program combined with an active surveillance process significantly reduced the incidence of Clostridium difficile (C. diff) infections in a long-term acute care hospital, according to a study published in the Journal for Healthcare Quality (JHQ), the peer-reviewed publication of NAHQ. C. diff is the second most common nosocomial infection in U.S. hospitals and patient risk factors include extended hospitalization, advanced age, multiple comorbidities, and exposure to antimicrobial products. C. diff is especially problematic in long-term acute care hospitals that treat ventilator-dependent and immune-compromised patients who have been treated with antibiotics. Patients with diarrhea are the major source of C. diff transmission via contaminated environments and the hands of healthcare workers. It is estimated that patients with C. diff infections remain hospitalized for an additional 7 days, and the estimated cost for each episode of C. diff is $5,000. Betsy Brakavich, MSN RN, vice president and chief nursing officer, Wellstar Windy Hill Hospital in Marietta, GA, reviewed results of a 2009 tiered infection control program in the 50-bed long-term acute care center. The program included environmental cleaning and disinfection, diagnostics and surveillance, and infection control measures, including antibiotic stewardship. The goal was to decrease the incidence rate of C. diff by 15% within 6 months. Prior to implementing the program, the environmental services staff received training on appropriate cleaning and disinfection of patient rooms. Microfiber mops were used instead of cotton strong mops because microfibers consistently remove a greater proportion of organisms associated with hospital-acquired infections. A new diagnostic test for C. diff was used for testing unformed stools, and patients with - 6 -

7 negative results were considered to be free of C. diff infection. Infection control measures included contact isolation for all patients with a positive diagnosis of C. diff. New isolation signs for patient room doors informed staff and families about appropriate isolation attire. Hand washing was strongly enforced, and hand sanitizers were removed from the rooms. Strict adherence to hand hygiene is an absolute necessity to avoid transmission of C. diff between patients and the community, said Brakavich. Antimicrobial stewardship steps included minimizing the frequency and duration of antimicrobial therapies and restriction of clindamycin and cephalosporins. Patients were assessed for signs and symptoms of C. diff before admission and were asked about antibiotics they had been taking. Prior to starting the C. diff control program, the hospital s incidence rate was After 12 months, the rate was and fell to after 2 years. The overall C. diff incidence at the end of 24 months had dropped by 44.25%. This study clearly shows the tiered program of environmental cleaning and disinfection, diagnostics, and infection control measures helped to decrease the incidence of C. diff in long-term acute care hospitals, said Brakavich. These are essential interventions for protecting patient safety. Editor s note: JHQ is free for all NAHQ members. To read any JHQ article, follow the directions on the journal web page. DID YOU KNOW We encourage you to submit an article, which may be about an interesting session or seminar that you have attended, your recent experience with JCAHO, project results, study or research results or anything that would be of interest to quality professionals. If you submit an article that is published in the newsletter, you will receive a complimentary conference registration to be used during the upcoming year (excluding the CPHQ review course). Please you submission to the Newsletter Co-Chair Laura Schwartze at laura.schwartze@hughes.net Please take advantage of utilizing the MAHQ website for information on upcoming events, job postings, Board Member, and resources. BOARD MEETINGS OPEN TO MEMBERS Board of Director s meetings is held monthly, ten months of the year. Meetings are usually held on the last Thursday of each month in rotating locations, for the convenience of the Board members. Some meetings are now conducted via teleconference. We welcome the attendance and input of the general membership, at all meetings. Contact the MAHQ President by (mahq.president@gmail.com) for - 7 -

8 information and directions. MARYLAND ASSOCIATION FOR HEALTHCARE QUALITY BOARD OF DIRECTORS 2013 PRESIDENT & STRATEGIC PLANNING COMMITTEE MEMBER CO CHAIR & NEWSLETTER COMMITTEE Laura Schwartze, RN-BC, MS, CPHQ PRESIDENT-ELECT & STRATEGIC PLANNING COMMTTEE CHAIR CO-CHAIR Gayle Hurt, MPA, CPHQ, PMC PAST PRESIDENT & STRATEGIC PLANNING COMMITTEE Gayle Hurt, MPA, CPHQ, PMC SECRETARY Nancy Doellgast, MPA, CPHQ TREASURER Bijoy Mahanti, RN, NE, BC MEMBER AT LARGE & STRATEGIC PLANNING COMMITTEE MEMBER Monica Cooke MA, RNC, CPHQ, CPHRM, FASHRM MEMBER AT LARGE &STRATEGIC PLANNING COMMITTEE MEMBER Tracy Nash, RN, BSN, CPHQ MEMBER AT LARGE Cynthia Burton BSN, RN MEMBER AT LARGE Eileen Curran-Thompson, RN, BSN MEMBER AT LARGE Linda Keldsen, RN, MBA-HC, CPHRM EDUCATION COMMITTEE CHAIR & MEMBERSHIP COMMITTEE MEMBER & MEMBER AT LARGE Peter Libby, RN EDUCATION COMMITTEE CO-CHAIR & MEMBERSHIP COMMITTEE CO-CHAIR Josephine Howard, RN, MS, CPHQ MEMBERSHIP COMMITTEE CHAIR & WEBMASTER Cheri Wilson, MA, MHS, CPHQ - 8 -

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