Place picture here Laying a “SAFE” Foundation Julie Apold Mickey Reid Minnesota Hospital Association

MHA Calls-to-Action Brief History AHE Law went into effect July 2003 Report any of the 28 National Quality Forum Serious Reportable Events  Event types with highest # of reports: Wrong Body Part Surgery Retained Foreign Objects Falls Pressure Ulcers

Focused Approach to Improvement  Focus on top events Determine Best Practices Implement Best Practices  Convened Advisory Groups Reviewed National and Local Best Practices Reviewed AHE Data Developed Implementation Best Practices

Patient Safety Roadmaps

MHA Statewide Calls-to-Action

Roadmap Work Group  Danielle Abel Lakewood Health Center  Mary Ellen Bennett Hennepin County Medical Center  Jane HarperMinnesota Department of Health  Sheila Higbe Olmsted Medical Center  Jane Hirst LifeCare Medical Center  Lindsey Lesher Minnesota Department of Health  Vicki Olson Stratis Health  Kate Peterson Stratis Health  Gail PriesGillette Children’s Specialty Healthcare  Jean Rainbow Minnesota Department of Health  Mickey ReidMinnesota Hospital Association  Linell Santella Park Nicollet Methodist Hospital  Cindi WelchEssentia Health  Boyd WilsonHealthEast Care System

SAFE from HAI Roadmap

Roadmap Structure  SAFE  Building Blocks  Infection-specific Gap Analyses

“SAFE”

SAFE = S (Safety Teams/Org Structure)  Action 1: Secure endorsements and resources for HAI Prevention Program Leadership: o Endorses the work o Clearly communicates goals o Regularly reviews progress toward goals o Supports adding resources as appropriate o Designates a senior leadership sponsor

SAFE = S (Safety Teams/Org Structure)  Action 2: Promote HAI prevention representation/champions/liaisons throughout the facility Regular Interdisciplinary team Champions Liaisons Ad-hoc for specific projects Designated coordinator(s) o With designated time!

SAFE = S (Safety Teams/Org Structure)  Action 3: Identify gaps and develop action plans The interdisciplinary team: o Reviews and updates the HAI prevention program o Reviews data results at least quarterly and identifies strengths and opportunities o Develops a plan to prioritize and address improvement opportunities o Commissions subgroups as needed

SAFE = A (Access to Information)  Action 1: Track progress on process and outcome measures Observational audits Inter-rater reliability Capture infection event details

SAFE = A (Access to Information)  Action 2: Review and analyze data for improvement opportunities Routinely review and analyze data Track progress against established targets o Run charts, control charts, dashboards, scorecards Prioritize and act upon identified issues

SAFE = A (Access to Information)  Action 3: Data is shared on a regular basis to promote system-wide learning and transparency Share vertically and horizontally A story with worth 1,000 data points

SAFE = F (Facility Expectations)  Action 1: Leadership establishes and communicates clear expectations All staff informed of expectations Culture supports speaking up/stopping the line The “stop the line” process clearly outlines: o When to stop the line o How to stop the line (verbal/non-verbal cue) o The chain of command to follow if not supported in stopping the line o Clear communication to staff from managers and leadership that staff will be supported if they speak up

SAFE = F (Facility Expectations)  Action 2: Education for HCP and prescribers Orientation Annually

SAFE = F (Facility Expectations)  Action 3: Establish a structured communication process Structured communication tools, e.g., Situation, Background, Assessment, Recommendation (SBAR); isolation signage A structured hand-off process (what should be communicated; how?) o During shift change o Between departments/units o To other facilities

SAFE = F (Facility Expectations)  Action 4: Disclose unanticipated events Promptly inform patients/families when an unanticipated event occurs that has potential to contribute to an HAI Establish who should discuss with the patient/family and how Provide training and support to staff on effective disclosure strategies Keep patient/family updated

SAFE = E (Engagement of Pts/Families)  Action 1: Educate and empower patient/ families Address any barriers to patient/family understanding their role in HAI prevention o Cultural, language, hearing impairment, health literacy Educated on their role and what they can expect to see from caregivers Assess patient /families’ level of understanding e.g., teach back Encourage “speaking up”

Building Blocks – Hand Hygiene

Building Blocks – Transmission Precautions

Building Blocks – Antimicrobial Stewardship

Building Blocks – Injection Practices

Building Blocks – Environmental Cleaning

Topic Specific Gap Analyses

Thresholds  Each infection topic area will have a process and outcome threshold  Thresholds incorporated into the dashboard and in the Registry home page  Goal: Assist in prioritizing efforts  The Patient Safety Registry will automatically recognize if thresholds are being met and provide a visual indication  If exceeding process and outcome thresholds, visual indication that threshold is met

Thresholds Healthcare Acquired Conditions Healthcare-Associated Infections Process MeasuresSAFE from HAI Roadmap Outcome MeasureInfection Rates Thresholds1) SSI and CAUTI = TBD (per NHSN) 2) VAP and CLABSI = 0 SourceMHA patient safety registry, Calls to Action; NHSN Criteria1.≥90% Safe from HAI Roadmap for 2 consecutive quarters 2. Rates below target Actions - If criteria metMonitor rates, if above target, begin quarterly roadmap updates Actions - If criteria not metContinued participation and quarterly updates for Safe from HAI

Data Submission Schedule  HAI Roadmap Data Updates Submit quarterly with other roadmap updates Baseline due September 30 (Grace-period - October 14 th )  Outcome Data Setting up agreement with hospitals submitting to NHSN designating MHA as user-group

Outcome measures  Current mandated state reporting (through MHA maintained website) VAP bundle Central Line Insertion bundle Surgical Site Infections (SSI) for Total Knee and Vaginal Hysterectomy  Federally IPPS hospitals report through NHSN: Central line infections SSIs (including colon and abdominal hysterectomy) More in coming years

Outcome measures  Move to align state and federal reporting Discontinue reporting through MHA site Begin reporting through NHSN o January 1 st, 2013 for IPPS hospitals Determine approach for non-IPPS facilities: o A staggered approach o Allow time for training and support of NHSN system o Consider attestation for low volume procedures o Tentative goal of first reporting for non-IPPS hospitals will be starting July 1 st, 2013

Roadmap Data Submission

New Hospital Reports – Action Plan

New Hospital Reports: Progress Report

New Hospital Reports: Section Report

New Hospital Reports: Gap Analysis

Dashboards  Patient Safety Dashboards are sent to CEOs quarterly  Gradual expansion of Dashboard  HAI Roadmap and Outcome data targeted to be included in dashboard 4 th quarter 2012

Next Step for SAFE from HAI  Sign-up for SAFE from HAI initiative Designate key contact Receive access to Patient Safety Registry for data submission  Complete SAFE from HAI Baseline by September 30th Use Gap Analysis Report to begin addressing gaps  Participate in Activities Listserv (automatically enrolled if in SAFE from HAI) Webinars/educational opportunities  Update SAFE from HAI Roadmap quarterly

Questions?