#PSA18 - United for Patient Safety

Each year, the Institute for Healthcare Improvement’s United for Patient Safety campaign culminates with Patient Safety Awareness Week. This year, Patient Safety Awareness Week is March 11-1. The week designates a dedicated time and platform to increase awareness about patient safety among health care professionals and the public. This month, IHI offers a number practical resources to help nursing homes implement changes to improve both patient safety and the safety culture. This resource list is not exhaustive, but it does offer initial guidance to facilities interested in patient safety initiatives.

I’ve also been studying leadership and a vision for a culture of safety. But what, exactly, is involved in building a culture, specifically a culture of safety? How do health care leaders, regardless of experience level, acquire and apply this skill? Given the relative lack of specific guidelines for leaders around safety culture, the American College of Healthcare Executives and the National Patient Safety Foundation (which has since merged with the Institute for Healthcare Improvement) recently convened expert panels to address these questions. The 2017 report from that panel, Leading a Culture of Safety: A Blueprint for Success, is designed as a practical, tactical guide for leaders at any stage in their organization’s culture transformation. I recommend reviewing it. The report suggests that leaders seeking to transform their organization’s culture should focus on six key areas:

  1. establishing a compelling vision for safety

  2. building trust, respect and inclusion

  3. educating and engaging board members in patient and workforce safety issues

  4. emphasizing safety in the development and recruitment of clinical leaders and executives

  5. adopting just culture principles to focus on system flaws, rather than individual blame, when things go wrong

  6. setting and modeling behaviors such as transparency, active communication and civility as expectations for all

Leading a Culture of Safety: A Blueprint for Success provides strategies and tactics for leaders to begin transforming their culture, as well as a set to help sustain progress. Different organizations will be at different starting points, and some may excel in one domain and seek to improve in another. Underlying all the work is a commitment to learning; continuous improvement; measurement, analysis, and interpretation of safety data; change implementation; and honest, open feedback.

Here are some resources organized by the composites assessed in the Agency for Healthcare Research and Quality’s nursing home survey on patient safety culture. For the complete updated list, visit the AHRQ.

Composite 1. Overall Perceptions of Resident Safety
1. Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices
This evidence report is featured on the AHRQ Health Care Innovations Exchange website. It presents practices relevant to improving patient safety and focuses on hospital care, nursing homes, ambulatory care and patient self-management. It defines patient safety practices, provides a critical appraisal of the evidence, rates the practices and identifies opportunities for future research.

2. Patient Safety Self-Assessment Tool
Steven Meisel, PharmD, designed this organizational self-assessment tool at Fairview Health Services using information from a report published by the AHRQ. The tool can help staff members evaluate whether known safety practices are in place in their organizations and find areas for improvement.

Composite 2. Feedback and Communication About Incidents
1. Call to Action: Safeguarding the Integrity of Healthcare Quality and Safety Systems
This provides best practices to enhance quality, improve ongoing safety reporting and protect staff. It addresses accountability, protection of those who report quality and safety concerns, and accurate reporting and response.

2. University of Michigan Health System Patient Safety Toolkit: Disclosure Chapter
The University of Michigan, with financial support from the Blue Cross Blue Shield of Michigan Foundation, developed this patient safety toolkit to build a foundation of knowledge and to suggest practical applications for developing best practices. One chapter is dedicated to disclosing medical errors or unanticipated outcomes.

Composite 3. Supervisor Expectations and Actions Promoting Resident Safety and
Composite 4. Management Support for Resident Safety

1. Appoint a Safety Champion for Every Unit
Having a designated safety champion in every department and patient care unit demonstrates the organization’s commitment to safety and may make other staff members feel more comfortable with sharing information and asking questions. This IHI Improvement website identifies tips for appointing a safety champion.

2 .Partnership To Improve Dementia Care in Nursing Homes: State Coalition Provider Question Worksheet
This provider self-assessment contains a list of questions for direct caregivers and nursing home leadership to assist facilities in assessing their approach to dementia care.

Composite 5. Organizational Learning 
1. Patient- and Family-Centered Care Organizational Self-Assessment Tool
The Institute for Healthcare Improvement developed this self-assessment tool in collaboration with the National Initiative for Children's Healthcare Quality and the Institute for Patient- and Family- Centered Care. It allows organizations to understand the range and breadth of elements of patient- and family-centered care and to assess where they are relative to the leading edge of practice. Use this self-assessment tool to assess how your organization performs in relation to specific components of patient- and family-centered care or as a basis for conversations about the organization’s patient-centeredness.

2. Quality Improvement Fundamentals Toolkit
The Oklahoma Foundation for Medical Quality developed this toolkit, which can be used to help identify opportunities for improvement and develop improvement processes.

Composite 6. Training and Skills
1. AHRQ Patient Safety Education and Training Catalog
The AHRQ’s Patient Safety Education and Training Catalog consist of patient safety programs currently available in the United States. The catalog, which is featured on AHRQ’s Patient Safety Network, offers an easily navigable database of patient safety education and training programs consisting of a robust collection of information, each tagged for easy searching and browsing. The new database identifies a number of program characteristics, including clinical areas, program and learning objectives, evaluation measures and cost.

2. Applying High Reliability Principles to Infection Prevention and Control in Long-Term Care
This educational module strives to introduce nursing home and assisted living employees to the principles of high reliability and how they can be applied to preventing infections in residents. The Joint Commission, with partial funding from AHRQ, developed this 50-minute e-learning tool. It features quizzes and a searchable database of practical resources. The free CDs and online format are available to all facilities, not just Joint Commission customers.

3. Improving Patient Safety in Long-Term Care Facilities: Training Modules
This training module is available on the AHRQ Health Care Innovations Exchange website. The “Improving Patient Safety in Long-Term Care Facilities: Training Modules” materials are intended for training frontline personnel in nursing homes and other long-term care facilities. The AHRQ, under a contract to the RAND Corporation, developed the materials.

They are organized into three modules:
Module 1: Detecting Change in a Resident's Condition
Module 2: Communicating Change in a Resident's Condition
Module 3: Falls Prevention and Management

Composite 7. Compliance With Procedures
1. Long-Term Care Toolkit
This toolkit is designed to help health care providers in long-term care facilities implement the 12 Steps to Prevent Antimicrobial Resistance Among Long-Term Care Residents. The Centers for Disease Control and Prevention developed these recommendations as part of its Campaign to Prevent Antimicrobial Resistance in Healthcare Settings. The toolkit follows the CDC’s 12-step framework and is divided into 12 sections, one for each step. Each step includes strategies on how to break specific links in the chain of infection, along with practical information, protocols, policies and tools that area easily customized for specific facilities.

Composite 8. Teamwork
1. Patient Safety Primer: Teamwork Training
Providing safe health care depends on highly trained individuals with disparate roles and responsibilities acting together in the patients’ best interests. The AHRQ’s Patient Safety Network further explains this topic and provides links for more information on what is new in teamwork training.

2. TeamSTEPPS® Long-Term Care Version
The Department of Defense and the AHRQ collaborated to develop TeamSTEPPS, a resource for training health care providers in better teamwork practices. The long-term care version of TeamSTEPPS adapts the program’s core concepts to reflect the environments in nursing homes and other long-term care settings.

Composite 9. Handoffs
1. Cooperative Network Improves Patient Transitions Between Hospitals and Skilled Nursing Facilities, Reducing Readmissions and Length of Hospital Stays
This featured profile is available on the AHRQ Health Care Innovations Exchange website. Summa Health System’s Care Coordination Network strives to ensure smooth transitions between the hospitals and 37 local skilled nursing facilities, leading to fewer re-admissions and shorter hospital stays.

2. Interventions to Reduce Acute Care Transfers (INTERACT)
INTERACT is a quality improvement program designed to improve early identification, assessment, documentation and communication about changes in skilled nursing facility residents’ status. INTERACT’s goal is to improve care and reduce the frequency of potentially avoidable transfers to an acute hospital. Such transfers can result in numerous hospitalization complications and billions of dollars in unnecessary health care expenditures.

Composite 10. Communication Openness
1. SBAR Technique for Communication: A Situational Briefing Model
The SBAR (Situation-Background-Assessment-Recommendation) technique provides a framework for communication between health care team members about a patient’s condition.

This downloadable tool from the Institute for Healthcare Improvement contains two documents:

  • “Guidelines for Communicating With Physicians Using the SBAR Process” explains how to carry out the SBAR technique.

  • “SBAR Report to Physicians About a Critical Situation” is a worksheet/script that a provider can use to organize information in preparing to communicate with a physician about a critically ill patient.

Composite 11. Nonpunitive Response to Mistakes
1. Leadership Response to a Sentinel Event: Respectful, Effective Crisis Management
The IHI periodically receives urgent requests from organizations seeking help in the aftermath of a serious organizational event, most often a significant medical error. In responding to such requests, the IHI drew on learning and examples assembled from courageous organizations that, over the last 15 years, have respectfully and effectively managed these crises.

Composite 12. Staffing
1. Consistent Assignment
The Advancing Excellence Campaign has identified best practices pertaining to consistent assignment. This website contains a collection of tools, guides and resources to help nursing homes get started.

General Resources
1. 2015 Long Term Care National Patient Safety Goals
The purpose of the Joint Commission Long-Term Care National Patient Safety Goals is to improve patient safety in long-term care settings by focusing on specific goals.

2. Long-Term Care Improvement Guide
Planetree, Inc. developed this guide to assist long-term care communities in their improvement efforts by presenting a collection of concrete strategies for actualizing a resident-directed, relationship-centered philosophy. It supplies providers with tools, data and practical resources so they can make informed decisions as they consider implementing culture change initiatives to deliver person-centered care.

3. Person-Centered Care
The Advancing Excellence Campaign identified best practices pertaining to person-centered care. This website contains a collection of tools, guides and resources to help nursing homes get started.

4. Pioneer Network
Pioneer Network is a center for all stakeholders in the aging and long-term care fields who focus on providing home and community for elders. This website features tools, articles and links for providers on culture change and quality improvement in nursing homes.

Please start the conversation between health care professionals and their patients to unite as members of the patient’s health care team. Working as a team and keeping open lines of communication allows both providers and patients to reduce harm and ensure the integrity of the care that is delivered. Here’s to #PSAW2018!