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Quality Quarterly: January 2009

OAHHS Governance Restructure: New Quality Committee

The governance of OAHHS has undergone a restructuring to address member needs in a more efficient and effective manner. The membership of the Board of Trustees has been right-sized to a representative group of 15.  This includes a physician representative and a hospital Trustees.  Also, five working Board committees have been formed, one of which is the Quality Committee. The committee is being formed now and membership will be comprised of hospital CEOs and quality directors. The goal of the Quality Committee will be to provide focus and input for the OAHHS Quality Program. For more information, please contact Diane Waldo, director of quality and clinical services. 503.479.6016 or email at diane.waldo@oahhs.org

Standardization of Overhead Emergency Codes

To address the variation of overhead emergency codes in hospitals, OAHHS partnered with the Oregon Patient Safety Commission and the Washington State Hospital Association (WSHA) to standardize emergency codes. Nine other states have responded to the lack of uniformity among health care facilities by standardizing emergency codes in their states. The American Hospital Association has endorsed the project and has recommended a set of codes for hospitals across the nation to use.

A task force representing key stakeholders from both Oregon and Washington was formed and worked through the fall and summer of 2008 to develop a hospital implementation tool kit. A tool kit was mailed to every Oregon hospital the week of January 12, 2009. Full implementation by every hospital is recommended by December 31, 2009.

This new set of standard code calls includes the following:

• Code Red = Fire
• Code Blue = Heart or Respiration Stopping
• Code Orange = Hazardous Material Spill or Release
• Code Gray = Combative Person
• Code Silver = Person with Weapon/Hostage Situation
• Amber Alert = Infant of Child Abduction
• External Triage = External Disaster
• Internal Triage = Internal Emergency
• Rapid Response Team = Rapid Response Team
• Click here to visit the Overhead Emergency Codes OAHHS website

Stop BSI (blood stream infections): New OAHHS quality project coming your way courtesy of Johns Hopkins

A major health care problem, for which a successful improvement model exists, is infections from central line catheters (CLABSI) in intensive care units (ICUs). Researchers from the Johns Hopkins University Quality and Safety Research Group (JHU QSRG) in partnership with the Michigan Health & Hospital Association Keystone Center (MHA Keystone),and clinicians and administrators from over 70 Michigan based hospitals nearly eliminated CLABSI in over 103 ICUs; an improvement that has been sustained for nearly four years.

Oregon has been accepted to work with Johns Hopkins University on the Stop BSI project beginning this spring.  We are joining 20 other states who have committed to participate in the project.

OAHHS is pleased to facilitate the implementation of the program for the intensive care units in Oregon hospitals over the next two years through conference calls and workshops. The commitment is staff time to participate; there are no other associated costs.

What is the intervention?

The project requires that ICU teams do the following:

1. Implement the Comprehensive Unit-based Safety Program (CUSP) to improve teamwork between doctors and nurses and learn from mistakes. This program includes five steps and that are both qualitative and quantitative.
2. Implement interventions to reduce CLABSI that include:

• Educate staff on five evidence based practices to reduce CLABSI;
• Implement a checklist to ensure compliance with these practices,
• Empower nurses to ensure doctors comply with the checklist
• Collect unit level data each month using standardized definitions
• Provide feedback on infection rates to hospitals and at unit level
• Implement a monthly team checklist to assess overall progress of project

What are the responsibilities of participating hospitals?

• Create and support a project team that includes at a minimum:
  • MD leader ( typically 20% effort)
  • Nurse leader (typically 20% effort)
  • Data collector (typically 10% effort)
  • Executive to participate with the project team (monthly meetings)
• Submit required infection data that is complete and on time (monthly and at baseline)
• Submit a monthly team checklist to provide insight on local project management
• Participate in project conference calls
• Participate in face to face meetings
• Implement improvement tools that are part of project
• Share team experiences within their hospital and with other participating project teams

WHO Surgical Checklist

The Oregon Node (six organization that have helped Oregon hospitals with the Institute for Healthcare Improvement (IHI) interventions include: OAHHS, Acumentra, Patient Safety Commission, CareOregon, the OMA, and the ONA) are collaborating to support the IHI's call for a Sprint to accelerate progress toward testing and full implementation of the World Health Organization Surgical Safety Checklist. The checklist has three parts: Sign In – Brief - Debrief and adds an element of teamwork to the universal protocol currently in use. The WHO study indicates that even hospitals with 94% compliance with using their own checklist had improvements in post surgical complications. Some sites found a 40% decrease in complications. A decrease in post-surgical complications translates to better patient outcomes and cost savings for hospitals.

The initial focus of the Sprint is for one surgeon to test the checklist in one operating room in every Oregon hospital by April 1, 2009. Experiences with the checklist indicate that the time involved for complex surgeries is less than five minutes. The node organizations will work to help Oregon hospitals with piloting and implementation of the checklist.

• Recent media coverage in the Oregonian

Multi Drug Resistant Organism (MDRO) Management: New OAHHS Safe Table

Efforts are underway to launch the MDRO Safe Table this spring. This Safe Table will represent a collaborative effort between Oregon APIC (Association for Professionals in Infection Control), Acumentra Health, and the Patient Safety Commission. Efforts for this project will build on a foundation of hand hygiene compliance (OAHHS Hand Hygiene Program) and expand to encompass best practice around the cleaning of patient rooms and contact precautions. Hospital staff will be invited to help establish consensus for standardized practice in Oregon and to develop a tool kit for member hospitals.

What's new at IHI

IHI plans to continue helping until patients everywhere receive the best care possible, every time. Building on the success of the 100,000 Lives and 5 Million Lives Campaigns, which concentrated primarily on reducing needless deaths and injuries, IHI will now help hospitals improve patient care by focusing on an essential set of process improvements needed to achieve the highest levels of performance in the areas that matter most to patients. IHI is calling this endeavor the "Improvement Map."

The Improvement Map will help you make sense of the many complex and competing demands you face by offering guidance. It will enable hospital leaders to distill from hundreds of requirements and measurements their own change agenda, and will help establish priorities, organize work, and optimize resources.

In the coming months, IHI will work intensely with national experts and innovative organizations to develop, field test, and refine components of the Improvement Map. Wherever possible, efforts will be coordinated with priorities established by other national organizations.

 The Improvement Map will cover the entire landscape of hospital care. Some of the interventions we already know: the 12 changes from the 100,000 Lives and 5 Million Lives Campaigns. The agenda will be expanded to include three new interventions:

• WHO Surgical Safety Checklist
• Prevent Catheter-Associated Urinary Tract Infections
• Link Quality and Financial Management: Strategies to Engage the Chief Financial Officer  and Provide Value for Patients

In keeping with the spirit of the Campaigns, IHI will continue to provide How-to Guides and introductory calls for all interventions at no cost.

Joint Commission News

NPSGs being reviewed during 2009

Over the next year, the current National Patient Safety Goals will undergo an extensive review. As a result, there will be no new NPSGs developed for 2010. Responding to concerns about the challenge some Goals represent and the need for information about effective approaches to addressing these challenges, The Joint Commission and its Patient Safety Advisory Group (formerly the Sentinel Event Advisory Group), which helps develop the NPSGs, are undertaking a thorough review of the goals and the process for their development. The NPSGs highlight serious patient safety issues that need to be addressed by health care organizations. As NPSGs have evolved over time, some have become more specific and detailed, and therefore, require more time and resources to implement.

Joint Commission report shows gains in safety, quality

In some very critical areas, Joint Commission-accredited hospitals in America have steadily improved the quality of patient care over a six-year period, saving lives and improving the health of thousands of patients, according a Joint Commission report. Improving America's Hospitals: The Joint Commission's Report on Quality and Safety 2008, an analysis of National Patient Safety Goal compliance, and hospital quality measures related to heart attacks, heart failure, pneumonia, or surgical conditions, provides scientific evidence of improved patient care. There were some dramatic improvements over the six-year period of data collection, especially in providing smoking cessation advice. For example, hospitals provided this advice to 98.2 percent of heart attack patients in 2007 compared with 66.6 percent in 2002. Hospitals greatly improved their results from 2002 to 2007 in providing this advice to heart failure patients (from 42.2 percent in 2002 to 95.7 percent in 2007) and patients with pneumonia (from 37.2 percent to 93.7 percent). Other strong improvements included providing discharge instructions to heart failure patients (from 30.9 percent to 77.5 percent) and providing pneumococcal screening and vaccination to pneumonia patients (from 30.2 percent to 83.9 percent).
 
However, the report does show that, for the third consecutive year, not all hospitals deliver the same level of quality and that some hospitals perform better than others in treating particular conditions. For example, hospitals provided discharge instructions to heart failure patients on average 92.1 percent of the time in the highest performing state, but provided discharge instructions 56.5 percent of the time in the lowest performing state. The performance difference among states is greater than 10 percentage points on 12 of the 24 quality measures tracked by The Joint Commission in 2007. There are exceptions to this variability. For example, virtually all—99.1 percent to 100 percent—accredited hospitals in the United States report that they measure oxygen in the bloodstream of patients with pneumonia. The Joint Commission issues this report as part of its ongoing efforts to emphasize the importance of accountability and continuous improvement for hospitals, and to empower consumers with information that will make them more active participants in their health care. Hospital-specific performance on specific measures for Joint Commission accredited organizations can be found on Quality Check® at http://www.qualitycheck.org/. For a complete copy of the report, visit http://www.jointcommissionreport.org/.

Universal Protocol

Recent changes to the Universal Protocol have been made and are detailed on the JC website: http://www.jointcommission.org/AccreditationPrograms/Hospitals/standards

Specific links to FAQs are noted below. Briefly, the universal protocol has been revised: The main revisions specify who must mark the site and what procedures must be marked.

• Marking the site: Formerly, a licensed independent practitioner (LIP) who was privileged to perform the procedure and who was going to be present during the procedure was required to mark the surgical site. Now, it is acceptable to utilize a PA (physician's assistant) or an advanced practice nurse to mark the surgical site. Note: Of course it is important to consider scope of practice, job description and have appropriate documentation of training for any staff person performing this function.
• What procedures must be marked: Surgical procedures with laterality (right or left) and level (e.g. vertebrae) must be marked to meet the JC requirement. Organizations can determine their own additional requirements for marking.