Menu Selection: Value of Participation:

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1 BETA Healthcare Group (BETA) is focused on improving reliability and reducing risk exposure in emergency departments. BETA provides our client hospitals and medical groups the opportunity for significant reduction in ED premiums each year of participation in the Quest for Zero: ED patient safety initiative. As participants demonstrate compliance with all elements of Tier1 (education), they may earn additional savings by advancing to the second tier (implementation of best practices in patient safety). Menu Selection: The Quest for Zero: Excellence in ED has various process improvement/risk reduction strategies for you to explore. To qualify for the ED premium renewal credit, 100% of all ED physicians, ED residents, PAs, NPs and nurses covered by BETA or HealthPro must complete the Personal Proficiency Module and associated Learning Path required for Tier 1 by the time of the validation assessment. Of note, Tier 1 now includes a performance improvement measure for those organizations taking a re-assessment of GNOSIS. Those desiring to advance to Tier 2 for extra credit must complete all required elements of Tier 1 before being eligible to receive any additional credit. The options found in Tier 2 allow you to set priorities based on trending risk-related issues specific to your organization or medical group. A description of each strategy, subcomponents, and associated metrics are contained within this ED Guideline applicable to the policy/contract year. The validation assessment will take place no later than 60 days before the policy renewal. Value of Participation: Tier 1 is valued at 2% of your ED premium. There is further opportunity to gain additional credits by choosing up to two additional options per year in Tier 2, each worth an additional 2% if all criteria are met. This represents a potential premium renewal credit of up to 6%. Get Started: We valued your enthusiasm and continued interest in BETA Healthcare Group s Quest for Zero: ED as we strive for excellence in emergency care. Please review this Quest for Zero guideline carefully. BETA Risk Directors and the Manager of Emergency Medicine and Patient Safety are available to provide guidance and further information to your staff and attend department or medical group meetings to ensure you have the information needed to achieve success in the coming year.

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3 Tier 1 Tier 1 is the foundation for the ED QUEST. This requires completion of the designated GNOSIS module. Tier 1 is worth 2% renewal credit

4 TIER 1 Must complete criteria in Tier 1 each year before credit is given for Tier 2 options Ongoing Education and Competency Requirement Findings Validation 1. The APS GNOSIS PPM assessment is completed by all physicians, residents, physician assistants, and nurse practitioners with ED privileges and coverage through BETA Healthcare Group or HealthPro no later than 60 days before policy renewal. 2. All ED nursing staff, (to include travelers and registry) must complete the GNOSIS PPM assessment within three months of hire, or assignment and no later than 60 days before policy/contract renewal. *HealthPro insureds must meet the requirement within their annual policy period The facility will provide the required documents to BETA by 60 days before policy renewal. BETA Healthcare Group will send a copy of the current provider roster to the hospital/medical group 90 days before renewal. The medical director or initiative lead must update the roster and return it to BETA 60 days before renewal indicating any new hires and those individuals no longer with the group. BETA will conduct a review of certificates of completion for 100% of physicians, physician assistants, and nurse practitioners covered by BETA Healthcare Group or HealthPro to confirm evidence of successful completion. Department director or designee will provide BETA with a current roster of all nursing staff assigned to the ED. Review of certificates of completion for 100% of ED nursing staff to confirm evidence of successful completion. 3. Based on GNOSIS Individual Learning Path, participant must complete all designated Red & Yellow Zones no later than 60 days before policy/contract renewal *HealthPro insureds must meet the requirement within their annual policy period Department director will provide BETA with a current roster of all nursing staff assigned to the ED. Review of certificates of completion for 100% of ED nursing staff to confirm evidence of successful completion.

5 Requirement Findings Validation 4. Those performing a reassessment of GNOSIS PPM must show a combined average score improvement of 1.5% in the knowledge domain A provider and nurse unit average in the upper 25 th percentile need only maintain that upper quartile. Produce APS analytics report showing with an overall increase in Knowledge Domain scores of 1.5% (or scores in upper quartile)

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7 Tier 2 Options Opportunity for extra savings Each option may yield an additional 2% renewal credit for a maximum of 6%

8 TIER 2 Participation on the ED Council 100% compliance in Tier 1 is required to receive premium credit in Tier 2 Requirement Findings Validation Identify two emergency department leaders to represent your facility on the ED Council Name submission by the deadline set by ED Council. o Team to include a physician leader and a nurse leader. These individuals do not need to be the department directors but should possess leadership authority in some capacity in the department Identify which of the team members will serve as the primary contact Attend a minimum of two full day inperson ED Council meetings as outlined in the ED Council Timeline o Team participation must be a minimum of 100% of all scheduled meetings and calls with at least one member of the designated team. Sign in rosters will be used to determine attendance at in-person meetings. Rollcall will be taken during all scheduled phone meetings and webinars. Lead or co-lead a subgroup as assigned by the ED Council. Complete all assignments by the agreed-upon deadline. Participate in initial research, craft recommended practices, establish outcome measures, pilot recommendations and provide feedback as outlined by the ED Council Memo of Understanding. Although participation is subjective, a fair and objective assessment of participation will be done, and BETA will have the final say in determining participation.

9 TIER 2 PEDIATRIC READINESS 100% compliance in Tier 1 is required to receive premium renewal credits in Tier 2 REQUIREMENT FINDINGS VERIFICATION PROCESS 1) The emergency department should designate a physician and nurse to act as primary pediatric care coordinators. a) In collaboration, the pediatric care coordinators will be the emergency department liaisons for pediatric care. b) Each will act as the resource for pediatric care for the respective disciplines and will work together to develop education, formulate policy recommendation, and provide recommendations for general hospital emergency care. c) Coordinate care recommendations with the respective hospital-wide committees to ensure continuity of care through the spectrum. Ensure that the hospital meets the minimum equipment recommendations set out in the AAP/ACEP/ENA Joint Position Statement Continuing Education for emergency department staff: All physicians shall complete and maintain current recognition in one of the following courses: the AHA-AAP Pediatric Advanced Life Support (PALS) course or the ACEP-AAP Advanced Pediatric Life Support (APLS) or equivalent. a. All full- or part-time emergency physicians shall have documentation of completion of a minimum of 2 hours of continuing medical education (AMA Category I or II) in pediatric emergency topics within a 2-year period. Discussion with the designated pediatric care coordinators. Review of appropriate committee minutes verifying the participation. Review of appropriate committee meeting minutes. A copy of the policy, procedure, and protocol submitted to BETA for review to ensure it meets the evidence-based recommendations. Review of staffing roster and education files.

10 REQUIREMENT FINDINGS VERIFICATION PROCESS b. It is recommended that all physicians caring for children in the emergency department take part in or facilitate the presentation of at least two pediatric mock scenarios annually. A mid-level practitioner is a nurse practitioner or physician assistant working under the supervision of a physician. 1. All nurse practitioners and physician assistants shall complete and maintain current recognition in one of the following courses: the AHA-AAP Pediatric Advanced Life Support (PALS) course, the ACEP- AAP Advanced Pediatric Life Support (APLS) course or the ENA Emergency Nursing Pediatric Course (ENPC). a. All full- or part-time nurse practitioners shall have documentation of a minimum of 2 hours of approved continuing education units in pediatric emergency topics within a 2-year period. b. All full- or part-time physician assistants shall have documentation of a minimum of 2 hours of continuing medical education (AMA Category I) in pediatric emergency topics within a 2- year period. Credit

11 Nurses REQUIREMENT FINDINGS VERIFICATION PROCESS for CME shall be approved by the Accreditation Council on Continuing Medical Education (ACCME), American Osteopathic Association Council on Continuing Medical Education (AOCCME), American Academy of Family Physicians (AAFP) or American Academy of Physicians Assistants (AAPA). c. It is recommended that all nurse practitioners and physician assistants caring for children in the emergency department take part in at least two pediatric mock scenarios annually. 1. At least one registered nurse (RN) on duty each shift who is responsible for the direct care of the child in the emergency department shall complete and maintain current recognition in the AHA- AAP Pediatric Advanced Life Support (PALS) course. All emergency department nurses shall complete and maintain current recognition in the above educational requirements within 12

12 REQUIREMENT FINDINGS VERIFICATION PROCESS months after employment. It is highly recommended that at least one ED RN per shift be certified in the ENA Emergency Nursing Pediatric Course (ENPC) AND the ENA Trauma Nurse Core Curriculum (TNCC) in addition to the PALS requirement. 2. Continuing Education a. All nurses assigned to the emergency department shall have documentation of a minimum of 2 hours of pediatric emergency/critic al care continuing education hours within a 2-year period. Continuing education may include, but is not limited to, PALS, APLS or ENPC; CEU offerings; case presentations; competency testing; teaching courses related to pediatrics; and publications. These continuing education hours can be integrated with

13 REQUIREMENT FINDINGS VERIFICATION PROCESS other existing continuing education requirements, provided that the content is pediatric specific. b. It is recommended that all staff caring for children in the emergency department take part in at least two pediatric mock scenarios annually. Ensure the emergency department policies are in line with the ACEP/ AAP/ ENA Joint position statement on pediatric care. Policies include: 1. Kilogram based weights 2. Triage of pediatric patients 3. Transfers of pediatric patients 4. Admission of pediatric patients 5. Pediatric medication formulary A copy of the policy, procedure, and protocol submitted to BETA for review to ensure it meets the evidence-based recommendations. Quality Improvement/ Quality Assurance Multidisciplinary Committee Review of the Emergency Department Quality review minutes. a. Pediatric emergency medical care shall be included in the emergency department Dashboard or quality improvement (QI) program and reported to the hospital QI committee. EMS representation should be considered as an addition to QI committee. b. Multidisciplinary continuous quality improvement (CQI) activities shall be established with documented

14 REQUIREMENT FINDINGS VERIFICATION PROCESS CQI monitors addressing pediatric care within the emergency department, with identified clinical indicators and outcomes for care. These activities shall include children from birth up to and including 18 years of age, and the Pediatric Dashboard shall consist of, but is not limited to, the review and tracking of all pediatric emergency department deaths, resuscitations, child abuse and neglect cases and interfacility (outbound or incoming) transfers. c. All nursing, mid-level and physician staff shall participate in no fewer than two mock pediatric scenarios annually. Scenarios ideally should be based upon real cases seen at the facility. Working in conjunction with the ED nurse pediatric care coordinator and ED physician pediatric care coordinator to ensure compliance with and documentation of the pediatric continuing education of all emergency department staff. d. Maintaining a data summary and working in conjunction with the multidisciplinary CQI committee to coordinate criteria-based review and follow-up of sample pediatric emergency department visits. e. Coordinating a review of pre hospital provider transported pediatric cases and providing feedback to the EMS System Coordinator. Participate in the Pediatric Readiness Project located at: Submission of documentation of participation.

15 TIER 2 CARE FOR THE CAREGIVER (PEER SUPPORT) 100% compliance in Tier 1 is required to receive premium renewal credits in Tier 2 REQUIREMENT FINDINGS VERIFICATION PROCESS A Care for the ED Caregiver Executive Champion and Team lead are identified to be actively involved in program development This should include a nursing and physician leaders. The department has assessed its current infrastructure and resources to support the development of a Care for the Caregiver program. The use of the CANDOR or BETA HEART Toolkit may be helpful in identifying the elements needed for a successful program. A Care for the ED Caregiver Committee is created to drive the program development forward. Recommended members include: Department Directors, Champions representing physicians, nursing, ancillary, residents, mid-level providers, social worker, employee health and pastoral care. A policy is in place specifying peer supporter response 24/7, intervention, follow-up, and support from the time of event through the investigation and litigation process. Determines the criteria for activation of the response. At a minimum should include any event or series of events that result in an increase of emotional stress in the department, for example: Executive leadership champion has been designated. There is department leadership represented on the committee. Department has completed a personnel resource assessment Review of roster for Care for the Caregiver Committee members Review of department policies as they pertain to adverse events, staff support program, and any other supporting material. Interviews with staff o o Family or co-worker dies in the department Child death

16 REQUIREMENT FINDINGS VERIFICATION PROCESS o o o o o Failure to rescue First death experience Unanticipated change in patient condition Patient harm (whether an error was made or not) Multiple patient traumatic events or deaths within a short period Policy includes criteria to determine the need for total team debrief (makeup of team is determined by event) Staff is aware that peer support is available A process is in place for identification and training of peer supporters. Peer Supporters sign a formal agreement defining their role and indicating their commitment to complete required training, be available to staff and maintain confidentiality of discussions Interview staff regarding the locations and availability of Safe Spaces Organization provides formalized training regarding resilience, burnout, fatigue and stress debriefing, crisis intervention, active listening, situational awareness, and recognition of signs and symptoms that a colleague may benefit from peer support

17 REQUIREMENT FINDINGS VERIFICATION PROCESS All unit supervisors, charge nurses, and other departmental leaders will attend full training Formalized training will be ongoing Care for the ED Caregiver plan requires trained peer supporters to be embedded within the department and available on all shifts and days of the week. The policy contains a mechanism for peer supporter to be available to emotionally traumatized staff within the department immediately after the event. A department peer supporter is available for each shift and day of week The process allows for peer supporter s routine responsibilities to be managed when assistance is needed for staff support. Review Care for the ED Caregiver policy (this requirement may be substituted for the organizational wide Care for the Caregiver policy). Review Peer Supporter Agreement Forms Review Care for the ED Caregiver s user feedback questionnaires for effectiveness of plan for immediate availability A peer support encounter form is used by peer supporters to document activities after events Encounter forms are used by the Committee to determine the need for additional resources or training Review of Committee meeting minutes A process for referring clinicians needing a higher level of support is in place and includes guideline criteria and mechanism for obtaining expedited access. Referral Network includes resources available both locally as well as Review of process and user feedback surveys

18 REQUIREMENT FINDINGS VERIFICATION PROCESS separate from the organization such as Chaplain Services, Social Workers, Clinical Psychologist, and Employee Assistance Program, etc. A process is in place to evaluate the effectiveness and staff satisfaction with the Care for the ED Caregiver program. User survey Peer Supporter Event form Review evaluation tool and results A measurement strategy is identified, implemented and included on department dashboard. Examples: # of Care for the Caregiver calls activated (peer to peer interactions) per month # of Care for the Caregiver interactions Types of referrals made (clinician self-referral/supervisor/rm/other) Effectiveness and timeliness of response (User survey) Timely access to higher level of support (User survey) Staff retention rates Review of department dashboard metrics for effectiveness of the program

19 TIER 2 Emergency Department Risk Assessment 100% compliance in Tier 1 is required to receive premium credit in Tier 2 Requirement Findings Validation Emergency Department Risk Assessment is scheduled with a BETA Risk Director no later than six months before the end of the policy period Emergency Department Risk Assessment scheduled Requested policies and forms must be submitted to BETA at least two weeks before assessment date: See Emergency Department Risk Assessment for requested policies and forms Requested interviews will be scheduled at least two weeks before the assessment At least three performance improvement plans with measurable outcomes will be developed based on the findings of the risk assessment, in collaboration with your BETA Risk Director: 1. Establish measurable goals or matrix for use in determining effectiveness of process improvement 2. Goals must be objective, clearly defined and measurable 3. Review plan and modify as indicated to achieve goal 4. Plans should be developed no later than 90 days before policy period The performance improvement plans must be submitted to appropriate medical staff and quality committees for review One plan must be completed by May 1 with evidence of measurable outcomes Submit policies and forms to BETA Risk Director Interview schedule sent to BETA Risk Director At least three performance improvement plans with measurable outcomes will be developed based on the findings of the risk assessment, in collaboration with your BETA Risk Director: Establish measurable goals or matrix for use in determining effectiveness of process improvement Goals must be objective, clearly defined and measurable Review plan and modify as indicated to achieve goal Plans should be developed no later than 90 days before policy period The performance improvement plans must be submitted to appropriate medical staff and quality committees for review Performance improvement plan with evidence of data collection Results should be submitted to medical staff and quality committees for review Committee meeting minutes with data review

20 TIER 2 Fracture Management And Follow-Up Care 100% compliance in Tier 1 is required to receive premium credit in Tier 2 Requirement Findings Validation Develop a radiology policy for the emergency department that at a minimum addresses the following: 1. Radiology overread process 2. Define which films should be read immediately vs. those that can be reviewed at a later time (time to be defined). 3. Define and list critical results 4. Communication process for overread to include: a. Responsible person to make contact with patient b. Follow-up plan with the patient c. Communication of anticipated plan for the patient 5. Log for communication and actions taken 6. QI process for misreads Policy Review Overread communication log: 1. A log should track all overreads, and include: a. Date/Time b. Findings c. Individual involved in the communication d. Method of communication e. Resolution 2. Ideally, the log should be electronic allowing access to both ED provider, radiologist, and quality coordinator. See example below. A redacted copy of the current Overread Communication Log will be provided to BETA for review by 60 days before policy renewal. Note: Names and patient identifiers should be redacted. All communications should be sent by secure with encryption. Date/Time Initial film Date/Time Over-read Date/Time ED Notification Date/Time Patient Notified Patient Follow-up Patient Name / MR# Test/Reason Ordering Provider Wet Read/ Clinical impression Radiologist Interpretation Further test recommendations Name ED Method of Date/Time Info to ordering MD physician notified notification message acknowledged Individual ED MD spoke with Spoke to whom? Communication Method Communication method Instructions provided Date/Time PMD notified Pt. Instructions Info to ED Medical Director Method used Resolved Not resolved Communicate with PMD

21 Requirement Findings Validation QI process for misreads: 1. Misreads are presented in Medical Staff Quality Committee and sent through the appropriate QI/QA paths including risk management. 2. Missreads are tracked by provider and be a part of Ongoing Physician Performance Evaluation (OPPE) Patient follow-up: 1. Develop a formalized process to followup to be sure that appropriate care is rendered 2. This step should include an outlined process for both inpatient and outpatient follow-up Site Visit Review Site Visit Review

22 Tier 2 Medication Management in the ED #1 of 5 Please note this option contains five elements for completion (ED #1 through #5) 100% compliance in Tier 1 is required to receive premium credit in Tier 2 Requirement Goal Validation The Quiet Zone is a dedicated area that is clearly marked. While in this area, staff are not to be disturbed until their task is complete. A medication safety quiet zone is implemented designed to provide a designated area for medication retrieval without distraction. Site Visit Review ISMP, 2016; IHI 2014 Compliance with this safety strategy is monitored on a monthly basis via observation of practice. Specified structure standards for safe use of five common medications administered in the Emergency Department are in place, and 100% compliance is evident with these structure standards. The following provide structure standards for the following: 1. Propofol 2. Narcotics 3. Heparin/ Low Molecular Weight Heparin 4. Electrolytes Performance improvement statistics Compliance with all structure standards contained in #1-5

23 Tier 2 Medication Management In The Ed #2 Of 5 Safe use of Propofol 100% compliance in Tier 1 is required to receive premium credit in Tier 2 Requirement Findings Validation Pharmacy prepares or purchases standardized premixed concentration ISMP 2014; CHA 2014 Dose concentrations are separated in the Automated Dispensing Machine in separate bins/ cabinets etc. Each bin/ cabinet containing a High-Risk Medication is labeled as a High-Risk Medication. ISMP, 2014; IHI 2014; CHA 2014 High-Risk Medication Policy designates Propofol as a high-alert medication and requiring a double-check. Procedural Sedation policy addresses the use of Propofol and reflects: 1. ACEP sedation guidelines 2. ASA Sedation guidelines 3. Staffing necessary for administration 4. Credentialing of those privileged to administer Propofol for procedural sedation 5. QI review of 100% of procedural sedation occurring in the emergency department for compliance with policy requirements ASA 2005; ACEP 2014; Site Visit Review Policy review Pharmacy procedures Policy review Site Visit Review Policy submitted for review Policy submitted for review Quality performance measures are recorded and submitted through QI/QA path. Action Plan is developed for those in non-compliance

24 Tier 2 Medication Management In The ED #3 Of 5 Safe use of Narcotics 100% compliance in Tier 1 is required to receive premium credit in Tier 2 Requirement Findings Validation Well defined opioid management policy that at a minimum includes the following items: 1. Frequency of monitoring and vital signs 2. Protocols for the use of reversal agents 3. Expectation for usage of smart pumps 4. Establish acceptable high and low limits for each medication administered via smart pump 5. Avoid use of overrides in the emergency department 6. Standardized concentrations available in the emergency department ISMP 2016; IHI, 2014 Work with the pharmacy to develop standardized concentrations that meet the needs of the patient population. Develop a re-evaluation schedule to adjust the formulary and concentrations needed in the emergency department. IHI 2014 Develop a fall prevention program for patients receiving narcotics/ opioids in the emergency department to include: 1. Staff education 2. Patient education 3. Monitoring 4. Observation and assistance in ambulation/ toileting. 5. Environmental safety measures IHI 2014; ISMP 2016; Policy review Site Visit Review Meeting minutes review Policy review Site Visit Review

25 Tier 2 Medication Management In The ED #4 Of 5 Safe use of Heparin and Low Molecular Weight Heparin (Lovenox) 100% compliance in Tier 1 is required to receive premium credit in Tier 2 Requirement Findings Validation Heparin ten thousand (10,000) units/ml will be stored in a separate bin/ cabinet and labeled as a high-risk medication on the outside of bin as well as on the medication container ISMP, 2006 Heparin one thousand (1,000) units/ml will be stored in a separate bin/ cabinet and labeled as a high-risk medication on the outside of bin as well as on the medication container ISMP, 2006 Heparin one hundred (100) units/ml doses will be stored in a separate bin/ cabinet and labeled as a high-risk medication on the outside of bin as well as on the medication container ISMP, 2006 A double check process by Pharmacist/Pharmacy Technician is in place during refill of the Automated Dispensing Machine (ADM). The Tech Check system is written as a formal pharmacy procedure The ADM drawer is labeled with high-risk sticker ISMP 2016; IHI 2014 Heparin/ Low molecular weight heparin are designated as a high-alert medication and require independent double-check before administration. This process is defined in the policy. ISMP 2016 Site Visit Review Site Visit Review Site Visit Review A copy of the Pharmacy procedure addressing the performance of double checks by pharmacy personnel when re-stocking high-risk medications will be provided to BETA no later than 60 days before the policy renewal period. Site Visit Review High-alert Medication Policy review

26 Requirement Findings Validation Smart pumps with built in high and low dose limits are used when infusing high-risk medications Smart pumps have the ability to program for the administration of bolus doses without the need to draw from a vial IHI 2014; ISMP 2016 When heparin solution is necessary to flush IV lines, the premixed solution is supplied by the pharmacy and not mixed by nurses on the unit. Low molecular weight heparin is is obtained from the pharmacy. Cohen; ISMP; IHI, 2014 Lab values (APTT) are double-checked by two nurses before adjusting IV dose heparin in accordance with the formalized protocol. Acceptable values are specified in the protocol and defined in policy Implement standardized weight-based dosing in accordance with evidence-based standards using preprinted orders or computerized order sets IHI 2014 Site Visit Review Pharmacy Procedure Policy Pharmacy procedure Heparin Policy Policy Site Visit Review

27 TIER 2 Medication Management in the ED #5 Of 5 Safe use of Electrolytes 100% compliance in Tier 1 is required to receive premium credit in Tier 2 Requirement Findings Validation Develop a policy on administration of electrolyte solutions to include: 1. Potassium Chloride 2. Magnesium Sulfate 3. Hypertonic Sodium Chloride 4. Calcium Chloride/ Calcium Carbonate Pharmacy provides standardized premixed concentration for loading dose of electrolytes in 50 ml or 100 ml volume solution Policy & practice restricts drawing bolus dose of electrolytes from main IV infusion ISMP 1999; ISMP 2005; Pharmacy provides standardized premixed concentration for maintenance dose of electrolytes in 250 ml or 500 ml volume solution ISMP 1999; ISMP 2005; Electrolytes are designated as high-alert medication requiring an independent doubleprior to administration.this process is formally defined in policy ISMP 1999; ISMP 2007; TJC Nurse to patient ratio is 1:1 during loading phase of electrolytes Policy review Site visit review Electrolyte policy review Site visit review Electrolyte policy review High-alert medication policy review Electrolyte policy review

28 TIER 2 Fall Prevention Program in the ED 100% compliance in Tier 1 is required to receive premium credit in Tier 2 Requirement Findings Validation A baseline evaluation of the current state of fall prevention strategies must be administered by month six of the policy year. Goals for improvement are based on findings To learn more access BETA s Fall Prevention Toolkit: Unit specific information regarding staff perceptions of fall safety across the emergency department is gathered utilizing a survey instrument. A 90% response rate by staff is required to ensure statistical significance. To learn more access BETA s Fall Prevention Toolkit: A policy is in place pertaining to fall management. To include at a minimum: 1. Universal fall precautions 2. Fall Scale(s) utilized 3. Criteria for utilization of Fall Scale 4. Prevention/ interventions 5. Post fall management 6. Communication/ documentation 7. Ongoing Fall Program Evaluation Clinical Pathway developed using validated fall assessment tool is in place and policy indicates level(s) of intervention required based on scoring criteria Department specific event trends (incident reports/qrr s/ Chart Audits) are shared and discussed at a minimum, quarterly, at medical staff quality committee and nursing staff meetings in an effort to identify trends develop potential solutions. Fall measures are adopted as a formal quality improvement metric, are monitored through quality, and compliance is reported up to the appropriate medical staff committee Review of notes/ minutes on process improvement committee evidencing current state review of fall prevention. Completion of Fall Knowledge Test by 100% of ED staff. Fall Management policy Site Visit Review Policy/Clinical Pathway review Minutes from QI/QA meetings, Staff Meetings, Dashboard Dashboard

29 TIER 2 Team Training Techniques 1100% compliance in Tier 1 is required to receive premium credit in Tier 2 Requirement Findings Validation A unit-based agreement to deploy TeamSTEPPs principles and a baseline readiness assessment is conducted and reviewed by senior leadership. Senior leadership supports the pursuit of team training in the emergency department setting as evidenced by the attestation of the baseline assessment. The baseline assessment tool may be found in BETA s 2017 ED Toolkit. Develop in-house staff as certified trainers utilizing the train the trainer methodology to deploy Team STEPPs training or other CRM training techniques. BETA has certified Master Trainers who are available to members and insureds as a complimentary service. For more information about the content, please contact Al Duke at al.duke@betahg.com. All staff that practice in the Emergency Department area is trained in TeamSTEPPS principles utilizing an interdisciplinary model of training.this includes all medical and nursing staff. The CAT s model of observation is deployed to measure performance and confirm adoption of CRM principles. Observations shall occur starting at the completion of the training. You may use the TeamSTEPPS Observation tool provided with the toolkit. The facility will provide the required documents to BETA by 60 days before policy renewal. Evidence of baseline readiness assessment findings and signed attestation of senior leadership s support of the principles. Evidence of certificates of completion of training of, at a minimum, two master trainers. Evidence of participation by all staff is reflected in dated sign-in sheets. Evidence of documented observations and results shall be provided 60 days before policy renewal.

30 TIER 2 Simulation And Drills 100% compliance in Tier 1 is required to receive premium credit in Tier 2 Requirement Findings Verification Process Utilizing an interdisciplinary approach, implement simulation or drills on two low frequency, high-risk events, annually. High or low fidelity simulation may be used. Simulation is best conducted in-situ through a simulation center may be utilized. Team members who respond to the specified emergency will be identified and shall be included in the simulation/drill exercise. This may include anesthesia, obstetrics, neonatal team members, lab or others The facility will provide the required documents to BETA by 60 days before policy renewal. Evidence of active participation by all required providers and staff as reflected in the facility/group s roster to be provided to BETA. BETA will issue Medical groups a copy of their provider roster for reconciliation by 90 days before policy renewal. Evidence of participation by all staff reflected in dated sign-in sheets Selection shall be based on events where there is potential for incidence, but rarely encountered to breed familiarity with clinical management. This may include: For example: 1. Inadvertent deep sedation 2. STEMI 3. Stroke 4. Newborn delivery 5. Septic shock 6. Multiple critical patients requiring triage of resources A debrief process is in place, and there is documented evidence of the debriefs, preferably written by staff, identifying individual learning Documentation of one opportunity, the associated corrective action, and measure of success shall be provided Scenario utilized shall be produced on day of validation Debrief summary of each simulation/drill scenario with an action plan as indicated. When action plans are called for, there should be indication items are completed. Documentation of corrective action and measure of success shall be produced on day of validation

31 TIER 2 Emergency Nurse Certification (CEN) Credential Certified Pediatric Emergency Nurse (CPEN) Credential 100% compliance in Tier 1 is required to receive premium credit in Tier 2 REQUIREMENT FINDINGS VERIFICATION PROCESS All eligible staff in the emergency department will sit for the CEN or CPEN exam before policy renewal. Those eligible are defined as: 1. Those currently licensed in U.S. 2. Recommend two years of experience in the emergency department. 3. CPENs must have documentation of two years of experience comprised of at least 1000 hours of practice time in a pediatric emergency department. Both time and hours must be met. Risk Management Resource Funds (RMRF) may be used to offset the cost of the exam. Evidence of current certification; enrollment and participation in the exam is required to meet this goal. Evidence of pass/fail is not required. The facility will provide the required documents to BETA by 60 days before policy renewal. Department director will provide BETA with a current roster of all nursing staff assigned to the ED. The roster should include the date of hire. Department director will provide BETA with evidence of enrollment and participation in the exam by all eligible RNs on the ED roster. For those already possessing a CEN, a copy of the certificates must be included. BETA evaluator will verify records indicating those who sat the exam and those who are eligible.

32 TIER 2 Culture Of Safety 100% compliance in Tier 1 is required to receive premium credit in Tier 2 REQUIREMENT FINDINGS VERIFICATION PROCESS Unit specific information regarding staff perceptions of patient safety across perinatal services is gathered utilizing a psychometrically sound, scientifically valid survey instrument. A 60% response rate is required to ensure statistical significance. The following instruments meet this requirement: Pascal HealthBench SAQ Agency for Healthcare Research & Quality (AHRQ) SCORE Survey by Safe & Reliable Healthcare RMRF s may be used to offset the cost of the survey A baseline survey must be administered by month six of the policy year. Goals for improvement are based on findings There is evidence that an annual survey will be conducted to measure performance The facility will provide the required documents to BETA by 60 days before policy renewal. Evaluator will review the evidencebased culture of safety assessment tool used to conduct the assessment. As above Evidence that the culture survey results were shared and discussed at medical staff committee and nursing staff meetings. Evidence of discussion is contained in meeting minutes ED Committee meeting minutes Nursing staff meeting minutes The culture survey results have been debriefed with nursing and medical staff in an effort to understand common themes in response to the results Evidence of participation by all staff reflected in dated sign-in sheets To raise staff awareness of safety concerns, at minimum, four case study presentations or M&M rounds are conducted to discuss error and near miss activity Evidence of participation by all staff reflected in dated sign-in sheets

33 REQUIREMENT FINDINGS VERIFICATION PROCESS Department specific event trends (incident reports/qrr s) are shared and discussed at minimum, quarterly, at medical staff committee and nursing staff meetings in an effort to identify trends develop potential solutions Evidence of participation by all staff reflected in dated sign-in sheets. Leadership WalkRounds are implemented by month six of the policy year and are conducted at least monthly. Specific information is obtained, recorded, and there is a feedback mechanism in place to address the patient safety issues that providers and staff voice as a concern. These issues are tracked and trended through a point of resolution. Activity sheets are collected and signed by the CEO, CNE or CMO; whoever is leading that particular WalkRound

34 TIER 2 Communication 100% compliance in Tier 1 is required to receive premium credit in Tier 2 Requirement Findings Validation Utilizing BETA Healthcare Group s certified trainer or an outside source through Vital Smarts, deliver a 2-day Crucial Conversations training to all staff who practice in the emergency department; or Utilize BETA Healthcare Group s trainers to deliver a one-day communications course to all staff who practice in the emergency department. Baseline readiness assessment must be completed by all staff For more information about the content or to arrange training through BETA, please contact Al Duke at al.duke@betahg.com The facility will provide the required documents to BETA by 60 days before policy renewal. Evidence of participation required for entire ED team whether or not covered by BETA. The facility will provide a roster of all ED medical and nursing staff, as well as all sign-in sheets. A unit-specific chain of command algorithm is laminated and posted in an area visible to all staff. Site visit review Implement SBAR handoff tool to ensure accurate and complete report. Track and monitor effectiveness of SBAR or another standardized communication format as a performance improvement measure on a monthly basis beginning no later than six months before policy renewal. This requires observation of compliance with the elements of the approved format. Evidence through chart review and or other record keeping if not contained in the chart Site visit review Documentation of, at a minimum, monthly observations starting no later than six months before your policy renewal to be provided to BETA.

35 TIER 2 Influence Change 100% compliance in Tier 1 is required to receive premium credit in Tier 2 Requirement Findings Validation The ED medical group director and hospital director of the emergency department (or designees) will attend Influencer Training or otherwise become familiar with the process through reading the Vital Smarts book, Influencer. Select one process for improvement that requires a change of culture utilizing the following: 1. Chart audits 2. Walkaround findings 3. Issues identified during simulation 4. FMEA Note: You may not select a process that is already mandated by CMS or other regulatory or accrediting agencies. You may not select a current PI process and modify it to fit into the Influences model Utilize the Influencer Model to structure the process for improvement. Identify a minimum of 4 sources of influence for implementation. Establish measurable goals or matrix for use in determining the effectiveness of process improvement. Conduct audits to determine progress and effectiveness of the plan. Modify plan as indicated to achieve the goal. The plan must be implemented no later than six months before evaluation for compliance. Provide updates to the Emergency medical staff committee or Quality committee. The facility will provide the required documents to BETA by 60 days before policy renewal. Provide documentation supporting the decision of process for improvement. Provide documentation indicating thought process for determining the sources of influence. Goals must be objective, clearly defined and measurable. Review of redacted committee meeting minutes for notations that PI progress is discussed during meetings and plan is modified to address barriers as necessary.

36 TIER 2 Triage Education 100% compliance in Tier 1 is required to receive premium credit in Tier 2 Requirement Findings Validation All Registered nurses (physician assistants, and nurse practitioners) conducting triage with ED privileges and professional liability coverage through BETA Healthcare Group or HealthPro must complete the required APS GNOSIS PPM assessment.based on individualized GNOSIS Individual Learning Path, participant must complete all designated Red, Yellow, and Green Zones no later than 60 days before policy/contract renewal New hires and newly credentialed practitioners may use certificates of completion for the required APS GNOSIS PPM taken elsewhere if completed within the previous two years of the policy renewal. Triage audit of 5 charts per nurse/pa/np who are covered by BETA Healthcare Group or HealthPro and performs triage, will be conducted twice a year to verify the accuracy of severity index and compliance with triage policy and protocols. Providers will receive feedback on audit findings and have the opportunity to review the record for educational purposes. This process will be documented. The facility will provide the required documents to BETA by 60 days before policy renewal. Review of certificates of completion for 100% of registered nurses, (physician assistants, and nurse practitioners conducting triage) covered by BETA Healthcare Group or HealthPro to confirm evidence of successful completion. Verified against a current staff roster. Verified by documents above. Provide a copy of the audit results to BETA. Review of Triage Policy Review of Performance Improvement plan for the Department.

37 TIER 2 Safer Sign-Out 100% compliance in Tier 1 is required to receive premium credit in Tier 2 Requirement Findings Validation Emergency medical groups must complete the sections of the EMPSF initiative required of physicians/pa s/np s. Policy/Procedure reflects Safer Sign Out concepts as the authorized hand-off process for use by physicians, PA s and NP s in the emergency department and requires the following elements: a. Use of a recordable form containing at a minimum all elements on the official Safer Sign Out tool. b. Pre-rounding with patients by the off-going provider to update Sign Out report i. Identify patient ii. Critical details iii. Follow-up items c. Requires joint focus on the available data (labs, imaging); occurs at the computer terminal between the on-coming and offgoing physicians/ providers. d. Requires joint rounding at the bedside i. Introduce on-coming provider ii. Update patient on his/her status iii. Ask if patient has any questions e. Requires the on-coming physician to update the nursing staff assigned to the patient of the patient's current status and provide the opportunity for the nurse to ask questions and provide input. f. Requires nursing staff to conduct their SBAR or similar formalized hand-off process between the off-going and oncoming nurse. g. Form used during the nursing hand-off must contain a place for both nurses to sign attesting that the hand-off occurred at the patient s bedside and that the oncoming nurse was allowed the opportunity to ask questions. The facility will provide the required documents to BETA by 60 days before policy renewal. The process must be in place a minimum of 6 months before qualifying for consideration to meet Tier 2. Copy of the Policy/Procedure/Protocol to be provided to BETA.

38 Requirement Findings Validation Evidence of the provision of process education to all clinical providers in the emergency department. Provide a document with medical providers and staff signatures reflecting education of policy s expectations. BETA hospitals: provide a copy of the ED nursing roster to BETA, include dates of hire. Medical Groups: Return an updated roster, reflective of current providers to BETA within 60 days of receipt of the roster from BETA.

39 TIER 2 SEPSIS BUNDLE 100% compliance in Tier 1 is required to receive premium renewal credits in Tier 2 REQUIREMENT FINDINGS VERIFICATION PROCESS Implement the Severe Sepsis Bundle recommended in the 2012 International Guidelines for Management of Severe Sepsis and Septic Shock. Implementation and QA must be in effect for a minimum of 1 year before qualifying for this option. 1. Develop a protocol for treating patients with sepsis- induced tissue hypoperfusion (hypotension persisting after an initial fluid challenge or blood lactate concentration 4) At a minimum the protocol must include: a. A screening tool to be used by nursing for prompt identification of patients likely to require implementation of the Sepsis Protocol. b. Measurement of lactate level promptly upon patient s arrival. c. When possible, obtain blood cultures as well as cultures from other likely sources of infection (urine, cerebrospinal fluid, wounds, respiratory secretions) before administration of antibiotics. If > than 45 minutes to obtain cultures, do not delay antibiotic therapy. d. Administer broad-spectrum antibiotics within one hour of presentation. e. If the patient is hypotensive or has lactate 4, administer a bolus of crystalloid at 30ml/kg within first three hours. Within first six hours if indicated: f. Administer vasopressors if hypotension is not responsive to initial fluid resuscitation to maintain mean arterial pressure 65mm Hg (Norepinephrine is identified as the drug of choice in septic shock). g. If persistent arterial hypotension despite volume resuscitation or initial lactate 4 mmol/l; measure central venous pressure and The facility will provide the required documents to BETA by 60 days before policy renewal. Copy of policy, procedure, and protocol submitted to BETA for review to ensure it meets the evidence-based recommendations.

40 REQUIREMENT FINDINGS VERIFICATION PROCESS measure central venous oxygen saturation. h. Remeasure lactate level if initially elevated. 2. Develop Screening tool for early identification of patients presenting with sepsis a. Define when the use of screening tool is indicated. b. If using electronic medical records, implement a trigger to capture the need for use of the screening tool. c. Provide training on the use of the tool for all ED nurses and other providers.required to implement to use the tool- such as PAs and NPs. d. Require all attending the education to sign-in, evidencing attendance. 3. Perform quality assurance to verify proper use and compliance with sepsis protocol a. QA to be performed on a monthly basis or more frequently. b. ED staff will receive individual coaching and feedback of personal compliance (both good and needing improvement). c. The medical director will receive the QA findings of physicians, PA s and NP s and will share the results (both good and needing improvement), on an individual basis with each provider. d. Results of Sepsis Protocol compliance will be presented at the Emergency Department Committee and Medical Staff Quality Committee meetings and be reflected in the meeting minutes. e. Barriers will be identified, and actions are taken to resolve the issues. f. By the time of qualification for this option of the Quest, physicians and staff will demonstrate a minimum of 90% compliance with the protocol. Provide a copy of the screening tool, ED nursing roster, and sign-in sheet to evidence compliance with this section. Evaluator will review the documents to confirm all staff required by the policy to implement the use of the tool received training and demonstrated an understanding of the use of the tool. Provide a copy of the monthly QA report section addressing compliance with the Severe Sepsis policy and evidence of individual feedback provided to staff and physicians. Provide a copy of the redacted Emergency Department and Medical Staff Quality Committee meeting minutes addressing the reporting of sepsis bundle compliance and reflecting at minimum 90% compliance with use of the screening tool and completion of tests and treatment within the recommended timeframes.