Adherence to Facility Procedures Is Key to Keeping Kidney Patients Safe

Non Adherence to Facility Procedures MODULE 4 Adherence to Procedures Non Adherence to Facility Procedures Failure to adhere to procedures, including the performance of routine completion of pre- and post-dialysis tasks such as taking patients' weight and blood pressure, leads to medical errors, increased risk of hospitalization and mortality. Non-adherence may also include failure to follow procedures regarding trouble with needle insertion and failure to complete event reports when medical errors occur. Non-adherence problems may reflect issues with procedural guidance, training, and/or enforcement.

Facts about Non-adherence to Facility Procedures More than one-third of nurses and doctors (37%) indicated that a patient’s blood sample was not taken when scheduled. 15% of respondents indicated that patients are sometimes not asked about their health concerns. 41% of respondents indicated that problems associated with a patient’s blood clotting sometimes occurred, and 29% indicated that a patient’s treatment sometimes had to be stopped before the session was completed. About half of patient care technicians, nurses, managers, and doctors (48%) indicated that their center has a written procedure for what to do if someone has difficulty inserting needles for a patient’s dialysis treatment. Among centers having written procedures detailing what to do when having difficulty inserting needles, about half of respondents (45%) indicated that staff are very knowledgeable about these procedures and only 15% indicated that staff are only somewhat knowledgeable about these procedures. Just over one-third of respondents (37%) did not know if their center had such a written procedure. Health and Safety Survey to Improve Patient Safety in End Stage Renal Disease, 2007 3

Common Areas of Non-Adherence Problems from multiple needle insertion attempts Patient’s blood pressure not taken Patient’s weight not taken Patient’s blood sample not taken when ordered Patient’s accesses covered Patient’s access not bandaged properly Machine stopped before treatment completed Needle dislodged Failure to report medical mistake

Factors Contributing to Non-Adherence to Facility Procedures Staff unfamiliar with procedures Not enough staff to handle work load Lack of counseling or disciplinary action when procedures are not followed Staff not comfortable reporting medical errors Staff not given proper training High rate of staff turnover Lack of continuous quality improvement programs Failure to educate patients about their care

Best Practices for Improving Adherence to Facility Procedures Develop a culture of safety and encourage a safe environment Review existing policies and procedures Develop standardized systems Develop patient safety plan Establish system for reporting errors Conduct root cause analyses

Culture of Safety A culture of safety includes: Patient-centered care Open communication Blame-free environment Shared responsibility for safety

The Medical Director’s Role in Safety To comply with the CMS Conditions for Coverage for ESRD Facilities, all dialysis facilities must have a medical director who is responsible for the delivery of patient care and outcomes in the facility. The medical director is accountable to the governing body for the quality of medical care provided to patients. In addition to those already mentioned, contributing factors to patient falls include: - Impaired Cognition - Degenerative Arthritis - Peripheral Neuropathy - Peripheral Vascular Disease - Lower Extremity Amputation and - Living Alone

Encouraging a Safe Environment The Medical Director and Facility Leadership should: Make staff accountable for safety, rather than focusing on an ineffective “name/blame/shame” atmosphere. Initial and ongoing training and education about safety practices, as well as activities to reinforce safety skills, can foster a safety-positive environment. Encourage reporting of errors and near-misses without fear of recrimination. Be sure staff members know that the facility prioritizes prevention of errors and near-misses. Prevention is best informed by errors and near-misses. Create clear systems for staff to share that vital information. Focus on systems improvement rather than blame. The goal is patient safety, which will be achieved by ongoing improvements to the facility’s system. Blaming individuals will not contribute to the goal. 9

Encouraging a Safe Environment The Medical Director and Facility Leadership should: Focus on being error-aware. Train staff and educate patients to be aware when something in the system is not working properly. This will enable individuals to anticipate the likelihood of error, focus on recovery to minimize the error, and work toward prevention of that error in the future. Support staff when an error is made. Team members focused on safety and prevention of future errors should learn from one another and provide support in these situations. Support may include physical assistance during recovery after an error, or emotional support. Reward staff for safe actions and/or reporting errors, near misses, and patients’ concerns. Recognize staff members who bring forth specific information, to encourage others to do so. Consider a “safety staff of the week” citation, monthly reward, or other recognition that draws attention of all staff to the importance of the reporting of errors, near misses, and patients’ concerns. 10

Developing Policies and Procedures Review current policies and procedures to ensure they meet current recommendations for preventing errors and adverse events. Review CMS Conditions for Coverage for ESRD Facilities. Consider using a process analysis fishbone or other root cause analysis to examine policies and procedures. Review examples of Quality Assessment and Performance Improvement (QAPI) projects and develop QAPI projects appropriate for your facility.

Standardized Systems Standardized systems reduce opportunities for error. Human errors can be caused by an individual’s short-term memory, judgment impacted by long hours, or problem solving during a stressful event. Standardizing processes and systems minimizes the possibility for errors due to the human limitations that even the most vigilant professional can have. Standardized systems will give staff the strength to decrease variation in patient care and, ultimately, improve safety.

Elements of Successful Patient Safety Plans Personnel: Successful patient safety planning relies on a team approach by all staff, directed and overseen by a Patient Safety Committee. Time: A facility must take time to put patient safety checks in place. This includes providing staff with sufficient time for training, implementing the plan, and continually monitoring and modifying the plan as the team works through real-life experiences of staff and patients. Technology: New or expanded patient safety systems may require IT updates. This may involve time and costs for updates, as well as staff training. Patients: Successful patient safety planning should involve patients as active participants in their care. Facilities should make a commitment to educating patients about their care so that they become, or continue to be, knowledgeable about what should be occurring during their own treatments. 13

Develop System for Reporting Errors/Adverse Events All staff—clinical, clerical, housekeeping, and maintenance—as well as patients, need specific, written directions on how to report errors or adverse events. There should be discussions to ensure that all team members clearly know what staff is responsible for responding to errors and near misses immediately. A reporting form should be created for documentation.

Conduct a Root Cause Analyses Once a continuing or evolving problem is identified through data tracking, the facility should conduct a root cause analysis to determine contributing factors, including a review of systems that were in place and determining if processes were followed. If not, there should be focus on staff training to prevent similar adverse events. If processes were followed but did not ensure patient safety, the Patient Safety Officer and other key staff should identify risks that could lead to further incidents and create solutions to prevent future errors that could lead to patient injury. 15

Root Cause Analysis – Process Analysis Fishbone A process analysis fishbone is a diagrammatic way to examine the policies, procedures, people, and equipment involved in a process leading to an outcome. It can be used to structure a brainstorming session. It immediately sorts ideas into useful categories. Providers may use the process analysis to develop Quality Assessment and Performance Improvement (QAPI) Projects.

Process Analysis Fishbone The Fishbone Diagram 1. Does NOT Use Cause-And-Effect 2. Modes Are NOT Dependent Upon Each Other 3. Uses Brainstorming Primarily 4. Allows Use of Opinion as Fact 5. Promotes Belief that All Causes are Within Categories Used

Fishbone Diagram Procedure Materials needed: flipchart or whiteboard, marking pens. Agree on a problem statement (effect). Write it at the center right of the flipchart or whiteboard. Draw a box around it and draw a horizontal arrow running to it. Brainstorm the major categories of causes of the problem. If this is difficult use generic headings: Method Machines People Materials Measurement Environment Write the categories of causes as branches from the main arrow. Brainstorm all the possible causes of the problem. Ask: “Why does this happen?” As each idea is given, the facilitator writes it as a branch from the appropriate category. Causes can be written in several places if they relate to several categories. Again ask “why does this happen?” about each cause. Write sub-causes branching off the causes. Continue to ask “Why?” and generate deeper levels of causes. Layers of branches indicate causal relationships. When the group runs out of ideas, focus attention to places on the chart where ideas are few.

Root Cause Analysis – 5 Whys The 5 Whys can also be used to find the root cause of a problem.  It leads the team to explore systemic explanations that go beyond: event-oriented excuses; the tendency to blame individuals; and a team’s inclination to first identify factors external to the system over which they perceive they have little influence. 5 Whys strategy looks at any problem and asks: "Why?" and "What caused this problem?“ Very often, the answer to the first "why" will prompt another "why" and the answer to the second "why" will prompt another and so on; hence the name the 5 Whys strategy.

Tips for Improving Adherence Audit staff regarding policy and procedures, including random questioning of staff about the facility’s specific policies Conduct visual checks Announce safety policies regularly throughout the day

MODULE 4 Adherence to Procedures

Which is NOT a factor in non-adherence to procedures? Staff not disciplined or educated when procedures are not followed Staff not comfortable reporting medical errors Staff has too much free time Staff not given proper training

Which is NOT a factor in non-adherence to procedures? Staff not disciplined or educated when procedures are not followed Staff not comfortable reporting medical errors Staff has too much free time Staff not given proper training

Which of the following are common areas of non-adherence to procedures? Patient’s blood pressure not taken Patient’s weight not taken Patient’s blood sample not taken when ordered All of the above

Which of the following are common areas of non-adherence to procedures? Patient’s blood pressure not taken Patient’s weight not taken Patient’s blood sample not taken when ordered All of the above

TRUE OR FALSE “Name/blame/shame” is an effective way to improve adherence to procedures.

TRUE OR FALSE “Name/blame/shame” is an effective way to improve adherence to procedures. FALSE Focus on systems improvement rather than blame. The goal is patient safety, which will be achieved by ongoing improvements to the facility’s system. Blaming individuals will not contribute to the goal. Make staff accountable for safety. Initial and ongoing training and education about safety practices, as well as activities to reinforce safety skills, can foster a safety-positive environment.

Additional Resources Keeping Kidney Patients Safe, Patient Safety Improvement Plan Basics http://www.renalmd.org/mpage/Patient_safety_tools Health and Safety Survey to Improve Patient Safety in End Stage Renal Disease http://www.renalmd.org/mpage/AboutKKPS Making Dialysis Safer For Patients Coalition https://www.cdc.gov/dialysis/coalition/index.html Cause Analysis Tools, American Society for Quality http://www.asq.org/learn-about-quality/cause-analysis- tools/overview/fishbone.html