Initiative Guidelines & Validation Tool (Revised 07/15)

Initiative Guidelines & Validation Tool (Revised 07/15) BETA Healthcare Group 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 this 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 required annual on-line education required for Tier 1 by the time of the verification assessment. The verification assessment process will begin no later than 60 days prior to the policy renewal. Those desiring to advance to Tier 2 for extra credit must complete all required elements of Tier 1 prior to being eligible to receive the additional credit. The options found in Tier 2 allow you to set priorities based on trending and risk related issues specific to your own organization or medical group. Each strategy and associated metrics are described in detail below. Value of Participation: Tier 1 is valued at 5% (or $5000 whichever is greater) of your ED premium. There is further opportunity to gain additional credits by choosing up to two 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 9%! Get Started: We value your enthusiasm and continued interest in BETA Healthcare Group s Quest for Zero preventable errors as we strive for excellence in emergency care. Please review this Quest for Zero guideline carefully. BETA risk managers are available to provide guidance and/or further information to your staff. Let us know if you plan on participating! We can attend departmental and medical group meetings to ensure you have the information needed to achieve success in the coming year. BETA must begin the evaluation of compliance no later than 60 days prior to your policy renewal. 1

TIER 1 Must complete criteria in Tier 1 each year before credit is given for Tier 2 options ONGOING EDUCATION AND COMPETENCY 1. All physicians, residents, physician assistants, and nurse practitioners with ED privileges and coverage through BETA Healthcare Group or HealthPro must complete the current year s on-line education by 60 days prior to policy renewal. 2. All ED nursing staff with coverage through BETA Healthcare Group or HealthPro must complete the current year s on-line education by 60 days prior to policy renewal. documents to BETA by 60 days prior to policy renewal. BETA Healthcare Group will send a copy of the current provider roster to the hospital/medical group by 90 days prior to renewal. The medical director or initiative lead must update the roster and return it to BETA by 60 days prior to 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 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. 2

Tier 2 Options Opportunity for extra savings Each option may yield an additional 2% renewal credit 3

TIER 2 100% compliance in Tier 1 is required to receive premium renewal credits in Tier 2 TEAM TRAINING TECHNIQUES (OPTION 1) 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 attestation of the baseline assessment. The baseline assessment tool may be found in BETA s 2015 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. Risk Management Resource Funds may be used to offset the costs of these train the trainer methods. For more information about the content please contact Al Duke at aduke@betahg.com. All ED staff are 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 completion of the training. You may use the TeamSTEPPS Observation tool provided with the toolkit. documents to BETA by 60 days prior to 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 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 prior to policy renewal. TIER 2 4

100% compliance in Tier 1 is required to receive premium renewal credits in Tier 2 SIMULATION AND DRILLS (OPTION 2) 1. All physicians, residents, physician assistants, nurses and nurse practitioners with ED privileges and coverage through BETA Healthcare Group or HealthPro, must participate In a minimum of two multidisciplinary simulations or drills annually. 2. Drills may use high or low fidelity manequins and may be in-situ or offsite. 3. A sign-in process exists to verify each identified team member completed the simulation and/or drills. 4. A roster of required nursing staff will be provided to BETA 5. Medical groups will provide a reconciliation of the BETA coverage roster to be returned to BETA. 6. All participating disciplines are identified prior to establishing the sim/drill scenario. 7. Two high-risk, low frequency issues will be pre-selected based on the organization s or national trends. For example: Inadvertent deep sedation STEMI Stroke Newborn delivery Septic shock Multiple critical patients requiring triage of resources 8. Evidence of a debrief process and lessons learned. documents to BETA by 60 days prior to policy renewal. Evidence of active participation by all required providers and staff as reflected on 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 prior to policy renewal. Evaluation/planning form which describes identified disciplines. Evidence of evaluation of high-risk/low frequency events. Debrief summary of each simulation/drill scenario with action plan as indicated. When action plans are called for, there should be indication items are completed. 5

TIER 2 100% compliance in Tier 1 is required to receive premium renewal credits in Tier 2 EMERGENCY NURSE CERTIFICATION (CEN) CREDENTIAL CERTIFIED PEDIATRIC EMERGENCY NURSE (CPEN) CREDENTIAL (OPTION 3) 1. All eligible staff in the emergency department will sit for the CEN or CPEN exam prior to policy renewal. Those eligible are defined as: Those currently licensed in U.S. Recommend 2 years of experience in the emergency department. 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. 2. Evidence of current certification; enrollment and participation in exam is required to meet this goal. Evidence of pass/fail is not required. documents to BETA by 60 days prior to policy renewal. Department director will provide BETA with a current roster of all nursing staff assigned to the ED. Roster should include date of hire. Department director will provide BETA with evidence of enrollment and participation in 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. 6

TIER 2 100% compliance in Tier 1 is required to receive premium renewal credits in Tier 2 CULTURE OF SAFETY (OPTION 4) Note: This option will take 2 years to complete. Year 1 qualification requires completion of #1,2,3,5,6,7,8. Year 2 qualification requires completion of # 4,5,6,7,8 1. Unit specific information is gathered through a survey process specifically targeting culture and teamwork behaviors in the emergency department setting. 2. Pascal HealthBench, AHRQ or similar evidence-based tool will be utilized for providing information back to the facility. 3. A baseline survey is obtained by the end of the first quarter of your policy period and goals for improvement are determined based upon the findings. 4. A repeat survey is conducted within one year (must be at least 60 days prior to policy renewal date) to measure improvement. 5. Results were analyzed and a report provided to the Quality Committee and the Board. *A 60% response rate is required for purposes of validity. 6. At minimum, four lessons from losses or case study presentations are shared at an ED staff and emergency medical staff committee meeting and are specific to medical error or near miss activity. 7. Department specific events trends (aka: incident reports/qrr s) are shared at least quarterly at ED medical staff and nursing staff meetings to documents to BETA by 60 days prior to policy renewal. Evaluator will review the evidencebased culture of safety assessment tool used to conduct the assessment. Evaluator will confirm the baseline assessment was provided to the ED physicians and staff with a minimum of 60% response rate. Review copy of the portion of the Quality Committee and Board meeting minutes evidencing receipt of the survey results.. Facility will provide a copy of the previous year s Quality Committee and Board meeting minutes (redacted to reflect only the portion directly related to the culture of safety survey process and results). Evidence of participation by all required staff through sign-in sheets. If staff or physicians were not present, evidence they were provided with and reviewed the information. Evidence of participation by all staff through sign-in sheets i.e. staff meetings/committee meeting or Emergency Department Committee 7

discuss trends and develop potential solutions. meeting minutes. 8. Leadership WalkRounds are conducted at least monthly. Specific information is obtained, recorded and a feedback mechanism is in place to address the patient safety issues that providers and staff voice as a concern. Record to include date, department, executive and front line participants, questions and comments, proposed action items and priority. 8

TIER 2 100% compliance in Tier 1 is required to receive premium renewal credits in Tier 2 COMMUNICATION (OPTION 5) 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. documents to BETA by 60 days prior to policy renewal. Evidence of participation required for entire ED team whether or not covered by BETA. 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. Observation Implement SBAR handoff tool to ensure accurate and complete report. Track and monitor effectiveness of SBAR or other standardized communication format as a performance improvement measure on a monthly basis beginning no later than 6 months prior to 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 Documentation of, at minimum, monthly observations starting no later than 6 months prior to your policy renewal to be provided to BETA. 9

TIER 2 100% compliance in Tier 1 is required to receive premium renewal credits in Tier 2 INFLUENCE CHANGE (OPTION 6) 1. 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. 2. Select one process for improvement that requires a change of culture utilizing the following: Chart audits Walk-around findings Issues identified during simulation FMEA Note: You may not select a process that is already mandated through CMS or other regulatory or accrediting agencies. You may not select a current PI process and modify it to fit into the Influences model 3. Utilize the Influencer Model to structure the process for improvement. 4. Identify a minimum of 4 sources of influence for implementation. 5. Establish measurable goals or metrix for use in determining effectiveness of process improvement. 6. Conduct audits to determine progress and effectiveness of plan. 7. Modify plan as indicated to achieve the goal. 8. Plan must be implemented no later than 6 months prior to evaluation for compliance. 9. Provide updates to the Emergency medical staff committee or Quality committee. documents to BETA by 60 days prior to policy renewal. Provide documentation supporting decision of process for improvement. Provide documentation indicating thought process for determining the sources of influence. Goals must be objective, clearly defined and measureable. Review of redacted committee meeting minutes for notations that PI progress is discussed during meetings and plan is modified to address barriers as necessary. 10

TIER 2 100% compliance in Tier 1 is required to receive premium renewal credits in Tier 2 TRIAGE EDUCATION PART 1 (OPTION 7) THIS OPTION CONSISTS OF THREE PARTS WHICH MAY BE COMPLETED OVER THREE YEARS- EACH QUALIFIES FOR 2% 1. 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 Sullivan Group on-line modules. Triage Fundamentals #01: Risky Business of Triage* Triage Fundamentals #02: Triage Practice Standards* Triage Fundamentals #03: Triage Assessment and Documentation (See end of this document for additional courses required for Part 2 and Part 3 which can be completed over subsequent years- each worth 2% renewal credit) * Facilities must purchase courses directly from The Sullivan Group. 2. New hires and newly credentialed practitioners may use certificates of completion for the required Sullivan Group courses taken elsewhere if completed within the previous 2 years of the policy renewal. 3. Triage audit of 5 charts per nurse/pa/np who is covered by BETA Healthcare Group or HealthPro and performs triage, will be conducted twice a year to verify accuracy of severity index and compliance with triage policy and protocols. 4. Providers will receive feedback on audit findings and have the opportunity to review the record for educational purposes. This process will be documented. Not Met Not Met Not Met Not Met documents to BETA by 60 days prior to 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. 11

Part 2 Modules Triage Fundamentals #05: Special Considerations at Triage Triage Fundamentals #06: Violence Potentials and Victims Triage Fundamentals #07: Customer Service Part 3 Modules Triage Fundamentals #08: Clinical Components I 9- Triage Fundamentals #09: Clinical Components II 10- Triage Fundamentals #10: Clinical Components III All other requirements within the option must be fulfilled each year seeking to qualify for the Triage option. 12

TIER 2 100% compliance in Tier 1 is required to receive premium renewal credits in Tier 2 SAFER SIGN-OUT (OPTION 8) Emergency medical groups must complete the sections of the EMPSF initiative required of physicians/pa s/np s. 1. 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 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 patient of thepatient 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 offgoing and on-coming 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 documents to BETA by 60 days prior to policy renewal. Process must be in place a minimum of 6 months prior to qualifying for consideration to meet Tier 2. Copy of the Policy/Procedure/Protocol to be provided to BETA. 13

patient s bedside and that the oncoming nurse was allowed the opportunity to ask questions. 2. Evidence of the provision of process education to all clinical providers in the emergency department. 3. Quality assurance of process includes: a. Review of shift Sign-Out forms to ensure form indicates the oncoming physician rounded with the off-going physician. b. ABEM forms may be used (See toolkit). c. On-coming physician/provider briefed the patient s nurse. d. Walk-round component to observe process taking place at bedside with observations documented. e. Action plan for any deviations of practice i. Action plan must include any identified barriers to compliance, actions to mitigate or remove barriers, target date for completion, responsible party, and evaluation of effectiveness of plan. f. QA must demonstrate a minimum of 90% compliance and reflect compliance by all providers with shifts within the implementation period. 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. Provide copy of QA audit tool and action plan to BETA. 14

TIER 2 100% compliance in Tier 1 is required to receive premium renewal credits in Tier 2 SEPSIS BUNDLE (OPTION 9) 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 prior to 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 minimum the protocol must include: 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) prior to administration of antibiotics. If > than 45 minutes to obtain cultures, do not delay antibiotic therapy. d. Administer broadspectrum antibiotics within one hour of presentation. e. If patient is hypotensive or has lactate 4, administer 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 documents to BETA by 60 days prior to policy renewal. Copy of policy, procedure and/or protocol submitted to BETA for review to ensure it meets the evidence-based recommendations. 15

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. Clearly define when 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 use of the tool for all ED nurses and other providers.required to implement to use of the tool- such as PA s and NP s. d. Require all attending the education to sign-in, evidencing attendance. Provide 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 understanding of the use of the tool. 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. 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 taken to resolve the issues. f. By 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 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. 16

TIER 2 100% compliance in Tier 1 is required to receive premium renewal credits in Tier 2 PATIENT AND FAMILY CENTERED CARE (OPTION 10) A readiness assessment is completed by a multidisciplinary team including senior leadership, a physician lead, nurse lead and one frontline staff member in preparation for deployment of a PFCC structure. Evidence of executed Readiness Assessment A policy is in place in the emergency department that is designed around including patients on improvement teams. This may be accomplished through the formation of a Patient & Family Advisory Council which includes perinatal services. In partnership with a patient partner, identify 3 areas of improvement to enhance the patient experience in your emergency department. Provide update to the Emergency Services Committee as evidenced in the meeting minutes. Develop an action plan with reasonable target dates for completion. Monitor changes for sustained implementation and report back through the Emergency Services Committee. The facility measures the patient s experience and patient satisfaction. A performance measure is outlined for the department. Emergency department satisfaction scores reflect performance in the 90 th percentile at minimum, or marked improvement toward that goal. Contact Al Duke @ aduke@betahg.com to verify your goal will meet the spirit of the initiative. Patient & Family Advisory Council Policy & Procedure Copy of the identified patient experience improvement opportunities. Provide copy of the Emergency Services Committee meeting minutes discussing the findings and action plan. Provide evidence of implementation of the changes and sustained gains. Provide copy of update report provided to Emergency Services Committee as evidenced by meeting minutes. Avatar, NRC Picker, HCAHPS scores 17

For clarification, questions, or consultation regarding the QUEST FOR ZERO: Excellence in ED Contact: Al Duke RN, M.B.A., B.S.N., CEN Manager of Emergency Medicine Patient Safety (818) 549-9479 aduke@betahg.com 18