MHA Patient Safety Organization

Transcription

1 MHA Patient Safety Organization Membership Benefits 2014 Copyright ECRI Institute PSO MHA PSO does more than analyze reported events and near misses. They provide members with tools and resources to help them prevent reoccurrences. Event Reporting Safe Tables RCA 2013 Copyright ECRI Institute PSO 1

2 MHA PSO Program MHA PSO Web portal Patient safety data collection and reporting system Comparative Reports MHA PSO and ECRI PSO Deep Dive Collaborative MHA and National Navigators Publications: PSMU, Monthly News Brief and E-lert Webinars/User Groups/Safe Tables Continuing Care Risk Management Custom Research Requests RCA Feedback and Analysis Michigan Patient Stories MHA PSO Web Portal 2

3 2011 Deep Dive: Medication Safety A report that has patterns and trends from the aggregated data submitted for medication errors A toolkit to assist healthcare facilities in considering safety strategies for medication administration The toolkit was used to identify gaps in an organization s medication administration practices 2012 ECRI Institute PSO Deep Dive TM Health Information Technology Inad-equate data transfer from one HIT system to another Data entry in the wrong patient record Incorrect data entry in the patient record Failure of the HIT sys-tem to function as intended Configuration of the system in a way that can lead to mistakes 3

4 ECRI Institute PSO Navigator National Distributed quarterly Role of Leadership What We Are Seeing - trends Lessons Learned best practices In the News Translating the data: Navigators Bariatric Patient Safety Health Information Technology Laboratory Testing IV Infiltration Medication Safety Patient Handoffs Falls Prevention PSO Navigators MHA PSO Navigator National Navigator 4

5 E-lerts E-Lerts Patient Safety Membership Update ECRI PSO Institute News Patient Safety Legal and Regulatory In the News Hazards and Recalls 5

6 Publications: PSO Monthly Brief Patient Safety Webinars (Quarterly) 6

7 User Group Calls (8x a year) Continuing Care Risk Management 7

8 Continuing Care Risk Management Continuing Care Risk Management 8

9 Custom Research Requests Level I:This research request is typically for a list of sources, guidance documents, or standards about a specific patient safety issue beyond the available PSO materials. The level of response time is typically 1-2 business days. Level II: This research request includes a list of sources, guidance documents, or standards about a specific patient safety issue beyond the available PSO materials and includes a report specific to the research request. The level of response time is typically 5-10 business days. Custom Research Requests Level III: This research request includes a list of sources, guidance documents, or standards about a specific patient safety issue beyond the available PSO materials; an analysis of the PSO facility data (if applicable), specific to the research request; and an evidence-based search with an in depth report of the data and a table of prioritized opportunities and resources to assist the PSO facility. The level of response time is typically business days. 9

10 Research Arm Guidelines; standards of care Latest in technology comparisons Custom Research Requests Falls and Hypnotics Hazardous Wandering and Elopement Pressure Ulcers RCA Evaluation Evaluate all RCAs: Process of the RCA & recommendations How do we use the data? Non-identifiable lessons learned in our PSO Navigator (Advisory) Database to aggregate contributing factors and root causes Aggregate the challenges throughout the process Individual feedback 10

11 Individual feedback Structure (Ability to define the problem; quality of RCA team) Investigative Process ( Data collection; documentation of problem) Factors (Assess contributing factors; identification of root cause) Strategies (Rate strategies) Limitations of the RCA technique that may be used RCA: Critique and Feedback Process Summary How thoroughly did you evaluate the event? 11

12 Detailed analysis of the RCA process Comprehensive Summary Scoring of RCA Recommendations How effective and sustainable are the action recommendations? 12

13 Practical Application of Resources Submit a Fall Event Send RCA for Review Improving Resident Safety Search CCRM Custom Research Request Additional Membership Benefits Continuing Care Risk Assessment Why Assess? Identify and manage risks in continuing care organizations (residential, assisted, and skilled care) Measure staff perceptions related to resident safety and risk Provides your risk retention group with information to use in planning education, toolkits, etc. 13

14 INsight Survey Overview Web-based survey Gather staff perceptions on key resident risk and safety areas Questions are based on industry standards and are specific to job functions Number of questions ranges according to job function Surveys take on average 30 minutes to complete The survey does not need to be completed in one sitting Respondents can access their survey from any computer with an internet connection, 24 hours a day, 7 days a week. INsight Survey 10 key areas Care Issues Elopement/Wandering Falls HR/Staff Development Medication Processes Organizational Culture RM/QI/PI Safety/Security Setting Realistic Expectations Transition of Care 14

15 Reports Provide facility reports Identify highest and lowest performing areas Benchmark against other organizations Establish risk management goals Culture of Safety Survey Overview Helps leaders evaluate and make improvements to the culture of resident safety positive safety culture. communications founded on trust, shared perceptions of safety, confidence in the efficacy of preventive measures.(ahrq) Based on the Agency for Healthcare Research and Quality (AHRQ) Nursing Home Survey for Patient Safety Culture Uniform survey for all staff 42 questions + 7 demographic questions = 51 questions 15

16 Twelve Key Areas 1. Teamwork (4 items) 2. Staffing (4 items) 3. Compliance With Procedures (3 items) 4. Training and Skills (3 items) 5. Non-punitive Response to Mistakes (4 items) 6. Handoffs (4 items) 7. Feedback and Communication About Incidents (4 items) 8. Communication Openness (3 items) 9. Supervisor Expectations and Actions Promoting Resident Safety (3 items) 10. Overall Perceptions of Resident Safety (3 items) 11. Management Support for Resident Safety (3 items) 12. Organizational Learning (4 items) Sample Questions Staff in this organization treat each other with respect. Staff are told what they need to know before taking care of a resident for the first time. My supervisor listens to staff ideas and suggestions about resident safety. Residents are well cared for in this organization. This organization is a safe place for residents. 16

17 Who should take survey? Questions? 2013 Copyright ECRI Institute PSO 17