Practice Quality RoundsPractice Quality RoundsTop 20 Questions that the Accreditation Surveyors will ask you!

Sue Fuller Blamey, Tricia McBain, & Tex Kissoon

May 25, 2012

1

Why is Accreditation So Important?y p

• Shows commitment to qualityq y

• Increases credibility and demonstrates accountability

• Validates areas of excellence in care deliveryy

• Identifies opportunities for ongoing improvement

• Supports recruitment and retentionSupports recruitment and retention

• Access to funding and grants

2

Survey Visit 2012y

• June 18 – 22 (C&W)• June 18 – 21 (CW Mental Health) • Last survey visit in 2008• 3 Accreditation Canada SurveyorsBC Children’s Hospital, Sunny Hill Health Centre

3

Accreditation: End in View

Goal: Accredited with Exemplary Standingp y g

* B d th t f hi h i it it i t f th

n/a100% of ROPS

* Based on the percentage of high priority criteria met of the grouped standards (Governance & Effective Organization, Managing Medications & Infection Prevention Control and g gall other service standards)

4

Culture of Safety Required Organizational Practicesq g

• Client safety as a strategic priority – adopts client safety as a written, t t i i it lstrategic priority or goal.

• Client safety quarterly reports – leaders provide the governing body with quarterly reports on client safety and include recommendations arising out of ad erse incident in estigation and follo p and impro ements madeadverse incident investigation and follow-up, and improvements made.

• Adverse events reporting – establishes a reporting system for adverse events, sentinel events, and near misses, including appropriate follow-up. The reporting system is in compliance with any applicable legislation and within any protectionsystem is in compliance with any applicable legislation, and within any protection afforded by legislation.

• Adverse events disclosure – implements a formal and open policy and process for disclosure of adverse events to clients and families includingprocess for disclosure of adverse events to clients and families, including support mechanisms for clients, family, staff, and service providers involved in adverse events.

• Client safety-related prospective analysis – carries out at least one client

5

• Client safety-related prospective analysis – carries out at least one client safety-related prospective analysis and implements appropriate improvements.

Culture of Safety Questionsy

• 1. Please tell us what you would do if you discovered a severe patient safety event in your area?

ROP: Adverse Events Reportingp g

Evidence: Always ensure the patient is safe and followed upThere is a reporting policy and process to report adverse

events, sentinel events, and near misses.S f t t t d f ll d d t k d i PSLSSafety events reported, followed-up and tracked in PSLS• Near Miss Projects in each agency to reduce the same type

of eventso e e s BCCH – Identification band compliance, Two identifiers/Mislabelled specimens

• FMEA: Reprocessing of OR Equipment

7

Culture of Safetyy

• 2. Tell us about your no blame culture at BCCH?

Becoming a High Reliability Organization (HRO)( )

• High-reliability-organization (HRO):practices help prevent catastrophic failures in complex

systemsh l bl i f f thave a palpable passion for safety,

see learning as inseparable from everyday work and a necessary precursor for change ecessa y p ecu so o c a ge

• Willingness to speak up and have an open discussion about errors in a non punitive /non-blaming environment

• Rigorous Analysis of patient safety events (PSEs) and near misses to reduce reoccurrence

• Sharing learning from PSEs: Patient Safety

9

• Sharing learning from PSEs: Patient Safety Alerts and Learning Summaries

Living a Just Culture (Non-punitive Response to Error)Response to Error)

Balances the need to learn from systems mistakesBalances the need to learn from systems mistakesand

the need for individual accountability when appropriate.

System Failures

•Learning from mistakesSt ff t h ld ibl f

Accountability

•‘Just Culture’ does not always mean ‘blame free”: individuals are•Staff are not held responsible for

system failures over which they have little or no controlSt ff ill i f i t t t

mean blame-free : individuals are held accountable for any instances of intentionally unsafe actions disregard for welfare of•Staff will receive fair treatment

when they report safety events

actions, disregard for welfare of patients or staff, or other wilful misconduct

10

Stop the Linep

• Stop the Line –pempowering staff to speak out if they feel a patient is at harm

• Allows anyone to ask th t fthe care team for a time-out if they have a question or concernquestion or concern about the patient’s care

11

Culture of Safetyy

• 3. Do you report those patient safety events that are “near misses or good catches”?

Importance of Near Miss Reportingp p g

• A near miss should be clear evidence that a tragic event could occur. An analysis of an organization’s near misses and actual patient safety events reveals a similar trending in the types of errors. Therefore, when organizations payin the types of errors. Therefore, when organizations pay attention to near misses and put strategies in place to prevent near misses, the number of actual patient safety events will also be reducedevents will also be reduced.

13

Near Miss vs Actual Patient Safety Eventsy

300

Number of "good catch" events vs adverse eventsfor BCCH

100

Number of "good catch" events vs patient safety eventsfor BCMHAS

50

100

150

200

250

300

50

100

0

10111213 1 2 3 4 5 6 7 8 9 10111213 1 2 3 4 5 6 7 8 9 10111213

2008/09 2009/10 2010/11

Good Catch Adverse Event

0

10111213 1 2 3 4 5 6 7 8 9 10111213 1 2 3 4 5 6 7 8 9 10111213

2008/09 2009/10 2010/11

Good Catch Adverse Event

100

150

Number of "good catch" events vs patient safety eventsfor BCW

0

50

10111213 1 2 3 4 5 6 7 8 9 10111213 1 2 3 4 5 6 7 8 9 10111213

2008/09 2009/10 2010/11

14

Good Catch Adverse Event

Disclosure

• 4. When would you disclose information to a patient/family about a patient safety event?

• 5. Name the steps in disclosure.

ROP: Adverse Events Disclosure

• ROP: Adverse events disclosure – implements a pformal and open policy and process for disclosure of adverse events to clients and families, including

h i f li f il ff dsupport mechanisms for clients, family, staff, and service providers involved in adverse events.

16

What is Disclosure?

The process by which an adverse event is communicated to the patient by the healthcare providers

Definitions taken from:Definitions taken from: Canadian Patient Safety Institute � Canadian Disclosure Guidelines

17

Patients Experience: 2 Types of Disappointment following an Adverse EventDisappointment following an Adverse Event

• The disappointing unanticipated medical outcomepp g p• The disappointing way the healthcare providers

behave after the unanticipated outcome

Research suggests patients are more forgiving of the first disappointment than of the secondthe first disappointment than of the second

18

(Hickson, 1992; Beckman, 1994; Vincent, 1994; Kraman, 1999; Gallagher, 2003, 2007)

What Patients Want from Disclosure

• An accurate explanation of what happened.

• Assurances that actions will be taken to reduce the chance of something similar happening again.chance of something similar happening again.

• An apology and recognition that there was a personal i timpact.

• Patients usually know when they have been injured as aPatients usually know when they have been injured as a consequence of an adverse event. If no explanation is offered, they assume a mistake has been made and is being concealed; they usually become angry!!!

19

being concealed; they usually become angry!!!

Steps of Disclosure p

Take immediate measures to stabilize the patientReport the patient safety eventInform physician leader and discuss follow-upDiscuss events with patient, family; acknowledge and/orDiscuss events with patient, family; acknowledge and/or apologize for eventDiscuss events with relevant staffReview actions taken to mitigate circumstances surroundingReview actions taken to mitigate circumstances surrounding the eventDiscuss corrective action to prevent similar adverse eventsRespond to patient family staff or service provider questionsRespond to patient, family, staff or service provider questionsOffer counseling to staff, service providers and patients/familiesDocument patient safety event and follow-up

20

Follow-up for patient to monitor and manage possible late/long term sequelae

Sample Surveyor Questionsp y

• 6. How do you communicate with patients and families about their role in patient safety?

• There is a patient safety patient/family booklet and a Patient Safety Care Provider Handbook.a e Sa e y Ca e o de a dboo

21

Medication Use

• 7. Does you organization limit the number and types of concentrated electrolytes, heparin and morphine products?

Summary of PT&N Reviews/New Policies Relating to ROPs

• Concentrated Medication Storage in Patient Care Areas (3 ROPs):(3 O s)

Concentrated Electrolytes Opioids

Heparins Heparins • Medication Order Requirements Policy (1 ROP):

Required Prescription elements Dangerous Abbreviations

• High Alert Policy (4 ROP) Identified List of Other High Alert (HA) MedicationsIdentified List of Other High Alert (HA) Medications

(including electrolytes, heparins and opioids Develop Safety Procedures for the identified medications

• Pre-printed Order Writing Policy (supporting above ROPs)

23

• Pre-printed Order Writing Policy (supporting above ROPs) Electrolytes, heparins and opioids Dangerous Abbreviations

ROPs: Heparins, Opioids, Concentrated Electrolytes

Accreditation Canada states the following are not allowed in gpatient care areas:

Heparin products greater than 50 000 units total quantityHeparin products greater than 50, 000 units total quantity

Hydromorphone products greater than 2 mg/mL concentration

Morphine products greater than 15 mg/mL concentration

Potassium salts (concentrated)Sodium salts > 0.9% (concentrated)

24

Phosphate salts (concentrated)

High Alert List(based on current policies and procedures)

opioidsopioids

anticoagulants

electrolytes

insulininsulin

chemotherapy

digoxin

investigational drugs

25

investigational drugs

List is currently being reviewed and revised by PT&N

New standardized continuous opioid infusion at BCCH

When prescribing- NEW pre-printed orders MUST b dMUST be used

Prescribed as/ pumps will read:pumps will read:

(mcg/kg/hr)

26

Medication Use

• 8. Does your organization have a “Do Not Use Abbreviations” List and where would we find it?

ROP: Dangerous Abbreviations

0.5 mg or 5 mg?

60 or 6 U ?

28

ROP: Dangerous Abbreviations

29

Required Organizational Practices

• Medication reconciliation at admission

• Medication reconciliation at transfer or discharge

• Medication reconciliation as an organizational priority

8. Please describe the medication reconciliation process in pyour organization.

30

ROP: Medication Reconciliation at Admission

BC Children’s:• When a patient is admitted from Emergency to either BC

Children’s or Children’s & Women’s Mental Health Program the most responsible physician (delegate)Program, the most responsible physician (delegate) completes medication reconciliation in consultation with the patient and family.

• Medication reconciliation is completed when admitting patients to in-patient units.

• In ambulatory care one clinic will be completing• In ambulatory care, one clinic will be completing medication reconciliation by June 2012 and this practice will be rolled out across BC Children’s ambulatory care

31

over the next year.

Medication HistoryIndicate patient’s

weight, height g , g& if applicable,

BSA

Indicate with a check mark ( ) patient’s allergy

t t If d tstatus. If any, document all allergies & reactions on the Caution Sheet.

I di t ith h k

, Indication

Indicate with a check mark ( ) if the patient has

NO home prescription, over-the-counter or

complementary alternative medications.

Complete date and time that you

obtained medication history. Place a

check mark ( ) in the Prescriber box.

And sign the signature line

Draw a line through admit med history list and order

form area to prevent

32

further documentation

ROP: Medication Reconciliation at Referral/ Transfer/Dischargeg

BC Children’s:• Inpatient oncology unit reconciles medications upon

transfer and discharge from the unit, in conjunction with the patient and familythe patient and family.

• There is a plan to roll this out to all in-patient units. • Similarly, one ambulatory clinic is currently reconciling S a y, o e a bu a o y c c s cu e y eco c g

medications upon transfer or discharge, and the practice will be implemented across ambulatory care over the next yearyear.

33

Required Organizational Practicesq g

• Client and family role in safety

• Information transfer

• Two client identifiers: proceduresTwo client identifiers: procedures

• Two client identifiers: medications

• Safe surgery checklist• Safe surgery checklist

• Verification processes for high-risk activities

34

Communication

• 9. How does your team transfer information to each other?

ROP: Information transfer

Demonstrated required evidence to meet ROP:

• Team has established mechanisms for timely & accurate transfer of information at transition pointstransfer of information at transition points Internal transfer of information External transfer of information

• Team uses the established mechanisms to transfer informationinformation

36

ROP: Information transfer

Safety Rounds and HuddlesRoutinely held with a set time• For exploration of potential near misses or actual harm

i th t k d/ h t ld l d t hin the past week and/or what could lead to harm• Interprofessional participations

Leadership Walkrounds• Introduces senior leaders to day-to-day issues at the front y y

line• Promotes communications between senior leaders and

front line staff

37

front line staff

Communication

• 10. How do you know that you have the correct patient?

ROP: Two client identifiers

Demonstrated required evidence to meet ROPs:

• Team uses at least two client identifiers before providing any service or procedureany service or procedure

• Team uses at least two client identifiers before d i i i f di iadministration of any medications

39

Before providing any service or procedure…

• Check for two client identification• Acceptable client identification:

Full nameBirth date Birth date

Medical Record Number (MRN) Provincial Health Number (PHN) Photo ID

• Ask patient to provide name & birth dateAsk patient to provide name & birth date• Compare patient ID bracelet to patient record or requisition• Confirmation of patient ID with parent or guardian

40

p p g

ROP: Two client identifiers: medications

• Medical Administration Record (MAR) checked ( )against prescriber’s orders, medication checked against MAR, patient ID bracelet checked before administration

• In BCCH and NICU, IV meds are checked with electronic barcode. Both are scanned into infusion pump to ensure right patient receives right medpump to ensure right patient receives right med

41

Communication

• 11. Tell us about the Safe Surgical checklist. Why do you use it, who participates in this and how many phases are there?

ROP: Safe Surgery Checklist

The team uses a safe surgery checklist to confirm f t t l t d b f b i i i lsafety steps are completed before beginning a surgical

procedure.

• Demonstrated required evidence to meet ROPs:The team has agreed on a three-phase checklist to be used in the operating roomused in the operating roomThe team uses the checklist before everysurgical procedure in the operating room

43

ROP: Safe Surgery Checklist (BCW &BCCH Only)( y)

The team has developed a process for ongoing monitoring of compliance with the checklist

The team evaluates the use of checklist and shares results with staff and service providersesu s s a a d se ce p o de s

The team uses results of the evaluation to make improvements to the implementation of and expand the use of the surgical checklist.

44

45

Worklife/Workforce

• Patient safety training and education • Patient safety plany p• Patient safety care provider roles and

responsibilities• Preventative maintenance program• Workplace violence preventionp p

46

Worklife Workforce

• 12. Does your organization have a Patient Safety Plan?• 13. Does your organization have a Patient Safety

Framework

Patient Safety Plany

• ROP: The organization develops and implements a client safety plan and implements improvements to client safety as required.

• Each agency has updated its Quality & Safety Plan• Each agency has updated its Quality & Safety Plan Patient Safety Rounds Executive Patient Safety Walkrounds

H d H i I iti ti Hand Hygiene Initiatives Trending patient safety events and improvement projects stemming from

trendsMedication Reconciliation Medication Reconciliation

Surgical wait time improvements Improved turnaround times from referral to clinic visit

Strategic initiatives for the organization

48

Strategic initiatives for the organization

PHSA Quality & Safety Framework

49

Worklife Workforce

• 14. Please describe your roles and responsibilities for patient safety in your organization?

• (What does this mean?)D if Wh t d d t k ti t f t th• Decifer: What do you do to keep patients safe at the BCCH?

Patient Safety Roles and Responsibilitiesy p

• ROP: The organization defines the roles, g ,responsibilities, and accountabilities of the organization’s leaders, staff, service providers

f fand volunteers for client care and safety.• Everyone has a role in contributing to patient

f tsafety• Embed patient safety in everything we do• Patient Safety Handbook for Health Care

Providers – revised and will be provided to all care providers or staff/physicians

51

providers or staff/physicians

Patient Safety Roles and Responsibilities

• Commitment to a Culture of Safety

• Consent to Treatment• Adverse Event and Incident

Managementg• Hand Hygiene• Non-punitive Reporting –

Hazards Injuries Harm AdverseHazards, Injuries, Harm, Adverse Events and Near Misses

• Stop the Line• Disclosure of Adverse Events• Disclosure of Adverse Events• Critical Patient Safety Event

Review

52

Worklife Workforce

• 15. Is patient safety part of your job description?

Patient Safety Roles and Responsibilitiesy p

• Patient Safety roles and responsibilities are y poutlined in position descriptions (below) and performance appraisals

• “In accordance with the Mission, Vision and V l d t t i di ti f th P i i lValues, and strategic directions of the Provincial Health Services Authority, patient safety is a priority and a responsibility shared by everyone atpriority and a responsibility shared by everyone at PHSA, and as such, the requirement to continuously improve quality and safety is inherent

54

y p q y yin all aspects of this position.”

Patient Safety Competencies

• Contribute to a Culture of Safety

• Work in Teams for Patient SafetySafety

• Communicate Effectively for Patient Safety

• Manage Safety Risks• Optimize Human and

E i t l F tEnvironmental Factors• Recognize, Respond to and

Disclose Adverse Events

55

Disclose Adverse Events

Worklife Workforce

• 16. Does your organization have a Workplace Violence Prevention policy and procedure?

• 17. Do your staff attend education about the Prevention of Workplace Violence?Workplace Violence?

Workplace Violence Prevention

• ROP: The organization implements a comprehensive strategy to prevent workplace violence.

• ¼ of all workplace violence occurs in health service organizations according to Accreditation Canadaorganizations, according to Accreditation Canada In BC: approx 40% of all violence related injury claims

occur in healthcare (even though healthcare makes up < 5% of the provincial workforce!)

• PHSA has a Preventing Violence in the Workplace policy (available on the POD)(available on the POD) Includes accountabilities and responsibilities for all staff,

leaders, physicians and service providers

57

p y p

• Module One: Workplace Violence Prevention IntroductionM d l T• Module Two: Recognizing andand Responding to Risk

58

Infection Prevention and Control

• 18. Please tell me one of the most important things healthcare providers can do to prevent infections in patients?

• 19 What are the average BCCH’s Hand Hygiene• 19. What are the average BCCH s Hand Hygiene compliance results?

Required Organizational Practicesq g

• Hand hygiene education & training - delivers education and training for staff, service providers, and volunteers on hand hygiene

• Hand hygiene audit - evaluates compliance with accepted hand hygiene practicesyg p

• Tracks infection rates - analyses the information to identify clusters, outbreaks and trends, and shares this information throughout the organizationorganization

• Infection control guidelines - adheres to international, federal and provincial or territorial infection prevention and control guidelines

• Influenza vaccine - Develops and implements an organizational policy and procedure for administration of the influenza vaccine

• Sterilization processes - monitors processes for reprocessing

60

equipment and makes improvements as appropriate

Hand Hygiene Educationyg

• Ongoing education• Orientation

All play a role: nursing

Hand Hygiene Program

• All play a role: nursing practice, quality leads, IPACS

• Physicians-on line e-learningIC d l PPE• IC module on PPE on learning hub

61

Your 4 Moments for Hand Hygiene

Hand Hygiene Educationyg

62

100%

Unit vs. Children’s Hospital Average Unit  vs. Children’s Hospital Average Trend

100%

574%

82.0%86.0%

70.1%76.1% 77.4%

70%

80%

90%

100%

e

70.1%

86.0%82.0%

64.4%77.4%

76.1%

72.2%

60%

70%

80%

90%

100%

ce57.4%

30%

40%

50%

60%

Percent Compliance

57.4%61.5%

45.7%

63.4%46.3%

30%

40%

50%

60%

Percent Complianc

0%

10%

20%

3rd Q 2010 4th Q 2010 1st Q 2011

0%

10%

20%

Audi t 1 Audit 2 4th Q 2009 3rd Q 2010 4th Q 2010 1st Q 2011

Unit Children's Hospital Average

AFTER Body Flu id Exposu re Risk3.BEFORE  Initial  Patient/Patient Environment 1.

Staf f ‐ Your  4 Moments For Hand Hygiene

Unit Children' s Hospital Average

63

AFTER Patient/Patient Environment Cont act4.BEFORE Asep tic Procedure2.

y p/Contact

May  2011

Falls Prevention – All agenciesg

• In Canada, falls prevention is a safety priority. Reducing falls and fall injuries increases client quality of life & reducesfalls and fall injuries increases client quality of life & reduces costs associated with serious injury from falls.

• Each Agency’s Falls Strategy has 3 elements g y gya) identifying at-risk patients through use of assessment tools. (Separate tools for Children and Women)b) i l ti ti t ifi i t tib) implementing patient-specific interventionsfor high-risk patients or areas. (Yellow dot on chart spine appropriate levels ofon chart spine, appropriate levels of observation/supervision, patient/family education specific to the nature of patient’s risk.)

64

education specific to the nature of patient s risk.)-c) implementing universal falls prevention strategies in all areas.

Falls Prevention

• 20. Does your organization have a Falls Prevention program and what do you do in your areas to prevent falls?

ROP: Falls Prevention - All Agencies

Tests for compliance to meet ROP:• Team implements a falls prevention

strategy (Each agency has a strategy in place.)• Strategy identifies the populations at risk for falls• Strategy identifies the populations at risk for falls

and includes education of patients and families • Strategy addresses specific needs of these populations.

(Each agency uses client-specific Assessment tools to identify levels of risk)

• Team establishes measures to evaluate falls preventionTeam establishes measures to evaluate falls prevention strategy on an ongoing basis. (Implementation audit and PSLS reporting and tracking)

• Team uses the evaluation results to make improvements to

66

• Team uses the evaluation results to make improvements to the strategy.

ROP: Falls Prevention – All Agencies

Universal Falls Precautions are ‘common to all’ precautions not specific to any agency, including:

• Partnership/education with families to increase awareness of falls and strategies that can prevent fallsof falls and strategies that can prevent falls.

• Orientation to the hospital or unit and review of safety brochure and posters.

• Non-skid footwear for ambulatory patients• Environment clear of unused equipment, hazards and ‘out

f l ’ f itof place’ furniture.• Environmental scans to ensure that facilities are accessible

and safe for those with mobility problems

67

and safe for those with mobility problems

• Predictable response, manageable with resources at hand Code Blue RESUSCITATION TEAM ORwith resources at hand

• Convey information to staff quickly with a minimum of misunderstandingP t t i ti t

Code Blue - RESUSCITATION TEAM ORNEONATAL RESUSCITATION TEAMCode Red - FIRECode Green - EVACUATION

• Prevent stress or panic among patients and/or visitors

• Supported by Policy

Code Orange - MASS CASUALTY – Internal or External EventCode Orange CBRN - Chemical, Biological, Radiological or Nuclear

• Can escalate to require a higher level of coordination or resources support –require activation of EOC

gCode Yellow - MISSING PATIENTCode Amber - CHILD ABDUCTIONCode Black - BOMB THREAT

Code White - AGGRESSIONCode Brown - HAZARDOUS SPILLCode Grey – SYSTEM FAILURE (including electrical power communications water medical gas

68

electrical power, communications, water, medical gas, vacuum)

EOC & Departmental Response Guides

Emergency Operation CentreA pre-designated facility established by

Room K0-155 (ACB)A pre-designated facility established by an agency or jurisdiction to coordinate

and support the overall response

Back up: Parent Craft Rooms (1U27)

69Emergency Operations Centre is activated by the Office of the Presidents

Disaster Suppliespp

• Located throughout the site• 1600+ 3 days• Food & Water – Search &

Rescue• Flashlights/radio/satellite phone• First Aid• First Aid

70

C&W Ethics Framework

• Overview of ethics and support available1 Ethics service 2 Ethics committees3 Research ethics board3 Research ethics board

• Appendices1 Ethical decision making tools2 Information brochure for pts/families3 Terms of reference

Available on POD and distributed in hard copy in programs

71

Thank You

72