BETA Healthcare Group is focused on improving reliability and reducing risk exposure in emergency departments. BETA provides our member hospitals and medical groups the opportunity for significant reduction in ED premiums each year of this Patient Safety Initiative. As participants demonstrate compliance with all elements of tier1 which focuses on education, they may advance to the second tier providing additional opportunities to enhance patient safety while further reducing ED premiums! 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, PAs, NPs and nurses covered by BETA or HealthPro must complete the required annual on-line courses required for Tier 1 by the time of the verification assessment, which is conducted no later than 30 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% of your ED premium. There is greater 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 (The Sullivan Group Audit option holds a value of 4%). This represents a potential premium renewal credit of up to 9%! Get Started: 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 complete evaluations of compliance no later than 30 days prior to your policy renewal; so be sure to schedule your verification audit 60 days in advance! 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.
TIER 1 Must complete criteria in Tier 1 each year before credit is given for Tier 2 options ONGOING EDUCATION AND COMPETENCY The Sullivan Group 1. All physicians, residents, physician assistants, and nurse practitioners with ED privileges and professional liability coverage through BETA Healthcare Group or HealthPro, must complete the current year s Quest Sullivan Group on-line modules by 30 days prior to policy renewal. 2. All ED nursing staff with professional liability coverage through BETA Healthcare Group or HealthPro must complete the current year s Quest Sullivan Group on-line modules within 30 days of policy renewal. 3. New hires and newly credentialed practitioners must complete: Risk & Safety Overview Part 1 Risk & Safety Overview Part 2 Within 30 days of starting and may complete the balance of the current year s modules by 30 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 by 90 days prior to renewal. The roster must include dates of hire. Review of certificates of completionfor 100% of ED nursing staff to confirm evidence of successful completion. Verified by documents above. Note: Providers may use certificates of completion for the required Sullivan Group courses taken elsewhere if completed within the previous 2 years of the policy renewal.
TIER 2 THE SULLIVAN GROUP CHART AUDITS (OPTION 1) Yields 4% renewal credit 1. Chart audits are conducted for the required focused diagnoses in accordance with The Sullivan Group exclusion criteria. Chart audits must: Include a minimum of 3 records per physician/pa/np for each required focused diagnosis. Part-time physicians and PAs/NPs may not have enough records meeting exclusion criteria to meet the 6-10 chart requirement. This is understood and each of these providers will be reviewed on an individual basis. Audit as many as are available meeting the exclusion criteria. Practitioners receive individual feedback of the results conducted by their initiative leader. At minimum, one additional chart audit consisting of 3 records per physician/ PA/ NP will be conducted to assess compliance progress. ABEM requirement for board certification requires 10 records per physician to qualify. Every practitioner must meet a minimum of 85% compliance with each required documentation element by the time of the verification review to qualify. Note: for hospitals conducting the auditsthere must be a 90% compliance with all required nursing documentation elements to qualify. 2. Participants should conduct periodic small sample audits of previous year s audit criteria to ensure the group is continuing to document the required elements and that new providers are complying. A review of the Sullivan Group Audit site will ascertain physician progress with the Quest. For providers lacking a minimum of 6 charts meeting exclusion criteria, evidence may be requested in the form of a report of patients presenting within the policy year with a complaint of chest pain. The BETA evaluator may conduct a periodic, random chart audit to confirm accuracy of audit findings. The initiative leader will be required to provide a list of medical records for each required diagnosis sorted by practitioner and arrange access to the requested records at time of the on-site verification review. The evaluator will determine the charts to be reviewed at the time of the visit. The hospital or medical group will be advised of the on-sight audit a minimum of 60 days prior of review. The BETA evaluator may conduct a periodic, random chart audit to confirm continued compliance with documentation requirements. A 60 day notice will be provided.
TIER 2 SIMULATION AND DRILLS (OPTION 2) 1. All physicians, residents, physician assistants, and nurse practitioners with ED privileges and professional liability 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 60 days prior to policy renewal. 5. Medical groups will provide a reconciliation of the BETA coverage roster to be returned to BETA within 30 days of policy renewal. 6. All participating disciplines are identified prior to establishing the sim/drill scenario. Evidence of active participation by all required staff as reflected on the facility/group s roster. Evaluation/planning form which describes identified disciplines. 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. 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.
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. Department director will provide BETA with a current roster of all nursing staff assigned to the ED by 90 days prior to renewal. 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.
TIER 2 CULTURE OF SAFETY (OPTION 4) Note: This option will take 2 years to complete. 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 end of first quarter of policy period (at the latest) and goals for improvement are set based on 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 discuss trends and develop potential solutions. Evaluator will review the evidence-based 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. 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 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.
TIER 2 COMMUNICATION (OPTION 5) 1. Training Option 1 Utilizing BETA Healthcare Group s certified trainer or an outside source through Vital Smarts, deliver a 1 or 2 day Crucial Conversations training to all staff who practice in the emergency department; a. Develop a process to monitor staff s ongoing grasp of the concepts. Ideas: -Electronic reminders at log-in -E-blasts of key concepts b. Monthly questions to staff to submit examples of how specific concepts were applied in the workplace- may ask them to think about examples prior to the meeting then share as part of the agenda each staff meeting, evidenced in the minutes. Option 2 Alternate training includes: TeamSTEPPS, MedTeams or other Crew Resource Management communication training must be taught by certified instructors and in accordance with program recommendations. a. Utilize weekly walk-rounds to observe for implementation of the process. b. Develop performance improvement measurement to assess effectiveness. c. Discuss use and opportunities during staff meetings and emergency committee meetings as evidenced in meeting minutes. Evidence of participation required for entire ED team whether or not covered by BETA. 2. 30 Second Debrief after critical patient event The charge nurse or designee will document that the debrief occurred (Log). a. This is a team learning experience and does not require detailed notes or action Review of Log or other source evidencing debrief process is occurring as a culture within the department and includes physicians, mid-levels and nursing.
plans unless there was a process issue triggering on-going risk if not addressed. An event report should be completed in the event of a process failure. 3. Clinical Chain of Command policy a. Policy is in place on the unit and specifies the measures to take when concerned regarding the medical care of the patient. b. Must demonstrate that all ED staff received education about the policy. 4. Formalized Hand-off Communication Process a. Implement SBAR or similar tool for use when giving hand-offs. b. A policy reflecting the expectations of hand-off communications is in place. c. Must demonstrate that all ED staff received education about the policy. d. Process must be monitored for utilization Ideas: -Random chart review -Observation during shift reports (must include all shifts) at least monthly with evidence of at least 6 months of use. e. Encourage feedback from receiving units when patient presents differently than represented during report. Investigate to see what happened and how to address any process failures. Document the process. 5. 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. Copy of the Policy to be reviewed. Staff signatures reflecting review of the policy will be verified against staff roster. Department director will provide BETA with a current roster of all nursing staff assigned to the ED and a copy of the Chain of Command policy by 60 days prior to renewal. Roster should include date of hire. Copy of the Policy to be provided to BETA by 60 days prior to renewal. Provide a document with staff signatures reflecting review of the policy. Provide a copy of the completed tool used to monitor for compliance with the policymonitoring to reflect all shifts. Provide a copy of the mechanism/tool used to receive feedback from other units of communication failures and opportunities for improvement; with action plan. Verification may include evaluator conducting random interviews with staff to verify the handoff process. Documentation of, at minimum, monthly observations starting no later than 6 months prior to your policy renewal.
TIER 2 INFLUENCE CHANGE (OPTION 6) 1. Utilizing BETA Healthcare Group s certified trainer or an outside source through Vital Smarts, the ED medical group director and hospital director of the emergency department will attend Influencer Training or otherwise become familiar with the process through reading the Vital Smarts book, Influencer. 2. Select one process for improvement 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. 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. 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.
TIER 2 NEW FOR 2013 TRIAGE EDUCATION PART 1 (OPTION 7) 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 Triage Fundamentals #04: Triage Policy, Procedure, Guidelines Triage Fundamentals #05: Special Considerations at Triage 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. 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. Verified by documents above. Provide a copy of the audit results to BETA Healthcare Group evaluator by 60 days prior to policy renewal.
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