Provider Resources
The following resources can help healthcare professionals improve the safety and quality of services to patients.
Quality Indicators
AHRQ Quality Indicators Toolkit for Hospitals: Improving Performance on the AHRQ Quality Indicators
Agency for Healthcare Research and Quality, November 2011
A toolkit to help hospitals understand AHRQ’s quality indicators and use them to improve quality and patient safety.
Communication
Words to Watch (National Patient Safety Foundation)
Many patients have trouble understanding words used by doctors and in healthcare institutions. This fact sheet provides a quick reference of words that patients struggle to understand and possible alternatives.
Inpatient Facilities
Rapid Response Teams
Rapid response teams play an important role in advancing patient safety by increasing the early detection of patients in trouble and identifying opportunities to prevent adverse events. The Institute for Healthcare Improvement describes the importance of establishing a rapid response team and provides a practical approach for getting started.
Pharmacy
Advancing Pharmacy Health Literacy Practices Through Quality Improvement: Curricular Modules for Faculty
Agency for Healthcare Research and Quality, December 2011
A set of modules to help pharmacy faculty integrate health literacy and health literacy quality improvement into courses, experiential education, and projects for PharmD students and pharmacy residents.
List of Confused Drug Names (Institute for Safe Medicine Practices)
A resource to help pharmacists determine when special precautions are needed to avoid medication mix-ups.
Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation (Agency for Healthcare Research & Quality)
This toolkit provides a step-by-step guide to improving the medication reconciliation process. The MATCH toolkit aides evaluation of the effectiveness of an existing medication reconciliation process and the identification and response to any gaps; emphasizes standardization of the process for doctors, nurses, and pharmacists within the facility to document and confirm a patient’s home medication list upon admission; and also emphasizes the need to clearly define roles and responsibilities of clinical staff.
Surgery
Preventing Wrong-Site Surgery (Pennsylvania Patient Safety Authority)
Analysis of wrong-site surgery events in Pennsylvania suggests opportunities for prevention. Many steps of preparing the patient for an operation and performing an operation can lead down the path of wrong-site surgery. Preventing wrong-site surgery may require attention at every step of the process.
Oregon Ambulatory Surgery Center Infection Prevention & Control Toolkit
The Oregon Ambulatory Surgery Center Infection Prevention & Control Toolkit is specifically designed to provide guidance on the development and implementation of infection prevention programs that meet infection control standards outlined in Medicare’s Conditions of Coverage and State of Oregon administrative rules. The toolkit was developed by the Oregon Patient Safety Commission to help Oregon’s ambulatory surgery centers (ASCs) implement infection prevention quality improvement projects, reduce infection risks, and better protect patients.
Introduction: Oregon Ambulatory Surgery Center Infection Prevention & Control Toolkit
The Oregon Ambulatory Surgery Center Infection Prevention & Control Toolkit is specifically designed to provide guidance on the development and implementation of infection prevention programs that meet infection control standards outlined in Medicare’s Conditions of Coverage and State of Oregon administrative rules. The toolkit was developed by the Oregon Patient Safety Commission to help Oregon’s ambulatory surgery centers (ASCs) implement infection prevention quality improvement projects, reduce infection risks, and better protect patients.
Nursing Homes Use Tool to Reduce Avoidable Hospitalizations
Communication is a key component in the INTERACT Tools (Interventions to Reduce Acute Care Transfers) that have been successful in reducing avoidable readmissions in Georgia nursing homes. A study of 20 Georgia nursing homes found that, of 200 hospitalizations, 134 (67%) were rated as potentially avoidable by long-term care health professionals. These findings led to the development of the INTERACT Tools to address communication, conditions commonly causing hospitalizations, and advanced care planning.
A second study found that implementation of the tools in three Georgia nursing homes with high baseline hospitalization rates was associated with a 50 percent reduction in the overall rate of hospitalizations and a 36 percent reduction in the rate of hospitalizations assessed as potentially avoidable. Due to the success of the tools, a revised version called INTERACT II is currently being rolled out in 30 nursing homes in New York, Massachusetts, and Florida.
One of the key INTERACT communication tools is SBAR (Situation-Background-Assessment-Recommendation), which has been broadly used in other healthcare settings to provide a standardized approach to information sharing that includes:
- S-Situation: What is happening at the present time?
- B-Background: What are the circumstances leading up to this situation?
- A-Assessment: What do I think the problem is?
- R-Recommendation: What should we do to correct the problem?
Because clinical teamwork often involves hurried interactions between healthcare team members (e.g., CNAs, nurses, physicians) with varying styles of communication, a standardized approach to information sharing ensures that patient information is consistently and accurately exchanged. This is especially true during nurse-physician communication that has the potential to result in unnecessary hospital transfers.
As many nursing homes are caring for sicker residents, building a foundation for improved communication presents an opportunity for nursing homes to effectively manage the care of their residents while avoiding preventable hospitalization that are associated with additional risks.
Community Pharmacist-Physician Teamwork May Prevent Falls
Results of a recent North Carolina study suggest that community pharmacists could have an impact on fall risk in older adults residing in the community. The study investigators recruited 186 participants 65 years of age or older, who had fallen at least once during the one year period preceding enrollment. All participants were taking medications associated with an increased risk of falling (benzodiazepines, antidepressants, anticonvulsants, sedative hypnotics, opioid analgesics, antipsychotics, and skeletal muscle relaxants). Half of the participants were randomly selected and invited to participate in a face-to-face medication consultation with a pharmacist.
The study results were published in two reports. The first report describes the number of recurrent falls in the year following the medication review. The second report describes physician responses to pharmacist recommendations and found that of the 41 recommendations for medication changes, only 10 were implemented and 6 of the 31 physicians contacted did not respond. The study concluded that while there were decreases in falls and injurious falls, the differences were not statistically significant and that coordination of care between community pharmacists and prescribers needs to be improved to benefit from the potential effects of medication management on falls prevention.
Community pharmacists can play key roles in identifying fall risks in older adults through a medication review. While a larger study is needed to determine the extent of risk reduction, the need for stronger relationships between community pharmacists and physicians is clear.
Two Oregon Hospitals Take Unique Steps to Improve Communication
In the quest for improved provider communication, two Oregon hospitals used entirely different approaches and tools, and both saw success. Rogue Valley Medical Center created and launched a bedside handoff program that has improved both patient care and staff morale. Oregon Health & Science University has developed a new culture change workshop to engage their nurses and physicians in examining unit safety, improving communication, and open discussion of strategies for improvement. Both of these efforts are being driven by hospital staff and have created notable impacts.
Rogue Valley Medical Center
The Orthopedic/Neurology unit at Rogue Valley Medical Center (RVMC) is participating in Transforming Care at the Bedside (TCAB), a national program developed by the Robert Wood Johnson Foundation and the Institute for Healthcare Improvement. This program engages front-line hospital nurses and leaders at all levels of the organization to improve quality, safety, team vitality, the patient experience, and overall team effectiveness.
RVMC used the TCAB approach to create and launch a robust bedside handoff program desired by front-line staff and developed by the nurses using the process. Nurses met weekly to discuss changes and refinements, developed a “flowing tool” to minimize redundant reporting, and developed a complementary tool for the charge nurse. To ensure a uniform process, nurses made a video of how to do a good bedside handoff and (just as importantly) how not to do a bedside handoff. All staff watched the video, took a quiz, and were certified by a TCAB team member; management was involved only to support the team. There was so much excitement about the process that every nurse on the unit was using the new tool before the official launch date. Unit manager Heather Mackey shared that communication has improved, potential near misses have been avoided, morale is up, and patient complaints are down from 4.66 per week to 3.42 per week in less than two months. When asked about their key to success, Mackey says, “I didn’t develop the tools – the team did. The decisions were truly made by the team.”
Oregon Health & Sciences University
Oregon Health & Science University’s (OHSU) Medical Intensive Care Unit (ICU) is dually enrolled in both the Oregon Patient Safety Commission’s Healthcare-Acquired Infection Prevention Collaborative and the Comprehensive Unit-based Safety Program (CUSP). CUSP, administered by the Oregon Association of Hospitals and Health Systems, is a structured framework to improve patient safety culture by engaging staff in identifying potential preventable defects, learning from defects that occur, and actively examining unit culture. OHSU’s Medical ICU used tools and ideas from the CUSP program to develop a culture change workshop series involving nearly all of their nurses and 75 percent of their physicians. Participants examined unit safety, improving communication, and openly discussing strategies for improvement. Each workshop involved 10-14 staff of different disciplines coming together for at least two hours and ultimately involved about 110 people. Using a variety of tools, surveys, and inspirational questions, participants surfaced ideas about staff satisfaction, patient safety and outcomes, and the inpatient experience. Together participants defined ideal communication as consisting of fewer physician pages, greater staff retention/satisfaction, a better patient experience, shared understanding of all plans, and better outcomes. OHSU is already seeing steps toward their goals and looking forward to a new workshop series on structured rounding using their new communication agreements and ideas from crew resource management.
Improving Patient Safety Through Provider Communication
A patient was given 30mg of Toradol in the operating room (OR); however, the medication was not reported to the recovery nurse. During the patient’s first 15 minutes in the post-acute care unit, the patient was restless and disoriented and complained of pain. One recovery nurse attended to the patient while a second recovery nurse retrieved Toradol per the post-operation orders. The first nurse drew up the Toradol and administered another 30mg to the patient, not knowing that the patient had already received Toradol in the OR. After the patient was resting and calm, the first nurse read through the chart, discovered her mistake, and immediately informed the anesthesiologist and surgeon.
-Event reported to the Commission
The Agency for Healthcare Research and Quality (AHRQ) recently released the sixth annual edition of the Hospital Survey on Patient Safety Culture: 2012 User Comparative Database Report, which provides survey results from 567,703 staff from 1,128 U.S. hospitals. The survey revealed that handoffs and transitions were the second most commonly identified area needing improvement. AHRQ reported that “only 45 percent of hospital staff have positive perceptions of handoffs and transitions across hospital units.”
Toolkit Instructions
Toolkit resources are designed to be customized by each ASC to ensure they address each ASC’s unique characteristics such as patient population and scope of services, and reflect current ASC policies and practices.
Section 1: Infection Prevention Program Development
The Centers for Medicare and Medicaid Services and the State of Oregon mandate that ASCs have an infection prevention program (IPP). Ambulatory surgery centers (ASCs) can use the tools in this section to ensure that an effective infection prevention program is established and quality improvement efforts are maintained. Resources provided in this section build upon one another and can be used to:
- Assess compliance with infection control practices
- Document assessment findings
- Use identified deficiencies to select areas for improvement
- Organize and analyze survey findings and surveillance data
- Establish and evaluate goals
- Conduct a complete infection prevention program evaluation and planning process
The planning process and annual assessment of the ASCs infection prevention program is critical. ASCs can use these tools and resources as documentation of the process used to perform annual program assessments, as a reference for future planning efforts, and as documentation of an ASC’s process for regulatory survey review. Web links provide additional information, resources, and tools.
Section 2: General Infection Prevention Practice
These materials can help ASCs comply with basic infection practices such as hand hygiene, surgical hand antisepsis, standard precautions, management of patients with potentially transmissible infectious diseases, Oregon’s reporting requirements for infectious diseases, and waste management. Web links provide additional information on applicable standards and helpful tools.
Section 3: Sterilization and Disinfection Practice
Learn about current regulatory standards and best practices for processing re-usable surgical instruments and equipment. This section includes sample policies, procedures, competency checklists, guidelines, and documentation forms for instrument/equipment cleaning, disinfection and preparation. Web links provide additional information, resources, and tools.
Section 4: Environmental Hygiene
Policies, procedures and tools provide information on appropriate cleaning and disinfection requirements and can be adapted for the ASC. Checklists can also be used for training purposes as well as to assure environmental hygiene quality. Web links provide additional information, resources, and tools.
Section 5: Safe Injection Practices
Materials in this section support the safe handling and use of needles and syringes, cannulae that replace needles, single-dose and multi-dose vials, and intravenous delivery systems and eye drops (where applicable). The section includes materials and references that address recommended practices for the safe handling and disinfection of blood glucose monitoring devices and medications. Web links provide additional information, resources, and tools.
Section 6: Employee Health Program
An ASC’s employee health program is an essential component of the infection prevention program. These sample policies and documentation forms include: healthcare worker communicable disease screening and immunization requirements, occupational exposure to communicable diseases, and blood and body fluid exposures. This section contains sample declination forms for Hepatitis B and Influenza immunizations. Web links provide additional information, resources, and tools.
Section 7: Quality Improvement
Tools in this section can assist ASCs in implementing changes at their facility and contain an example of a safe surgery checklist (based on one published by the World Health Organization) that was developed by an Oregon-based group representing multiple state professional organizations and agencies. Web links provide multiple patient/family educational tools that may be used at the ASC.
Communication Style and Resistiveness to Care in Dementia Residents
About 65 percent of Oregon’s nursing home residents are cognitively impaired (very mild to severe). Caring for this population can present complex challenges to providers. How nursing home staff communicate with these residents can actually increase care challenges. A study at the University of Kansas School of Nursing suggests that adult nursing home residents with dementia are more resistant to care when talked to like children. The study explored the relationship between nursing home staff communication with dementia residents and subsequent behaviors that disrupt care, often called resistiveness to care (RTC). Specifically, the study examined the impact of “elderspeak” on RTC behaviors.
Pre-Surgical Informed Consent: Improving Patient Understanding
Typical patient education programs consist of pamphlets given to the patient prior to surgery and verbal instructions the day of surgery. Because ambulatory surgery patients play a critical role in their own care management, preoperative education and patient understanding about the surgical process and what to expect is particularly important.
Successful Patient Engagement at Poudre Valley Health System
Increasingly, hospitals are recognizing that patient centered care is not only the right thing to do, but that it can lead to increased patient satisfaction, better care, and decreased costs. The Poudre Valley Health System in Colorado uses a number of different strategies that allow them to effectively engage their patients.
Engaging Patients & Families for Safe, Quality Care
A 71 year-old male was discharged home following a colonoscopy. A short time later the patient started having progressively severe abdominal pain and went to the ED where a CT scan revealed evidence of a bleed and a slightly enlarged spleen. It was discovered that the patient had not discontinued his Coumadin prior to surgery as indicated in his pre-surgical instructions. He was admitted for monitoring and received six units of blood.
- Event reported to the Commission
Breakdowns in communication were one of the top three leading root causes of sentinel events reported to The Joint Commission in the United States between 2004 and 2011. These communication breakdowns occurred among healthcare professionals and also between healthcare professionals and patients or families. The Oregon Patient Safety Commission’s aggregate summaries of events reported in 2010 by Oregon hospitals, nursing homes, and ambulatory surgery centers identified similar trends in Oregon. In hospitals, communication concerns were a contributing factor in two out of every three events reported (66% of the time). In both nursing homes and ASCs, communication was among the top three reported factors that contributed to adverse events.
Putting Safe Surgery Checklists to Use
Hospitals
Some time ago, The New England Journal of Medicine reported that use of a simple checklist significantly reduces surgical complications and death. As of November 2010, all of Oregon’s 56 acute-care hospitals that perform surgery were using the checklist or pursing checklist implementation.
Press Release: Oregon Hospitals Make Surgery Safer
Oregon Map of Checklist Adoption
Oregon IHI Network Safe Surgical Checklist (adapted from the WHO Surgical Safety Checklist)
Ambulatory Surgery Centers
The Centers for Medicare and Medicaid Services (CMS) is calling on all ambulatory surgery centers (ASC) to use a safe surgical checklist starting January 1, 2012.
