Proven strategies for tough-to-measure NPSGs
Proven strategies for tough-to-measure NPSGs
Tips for handoff communication, hand hygiene
Some of the Joint Commission's National Patient Safety Goals (NPSGs) are easier to monitor than others, such as reducing the likelihood of harm associated with the use of anticoagulants, which can be tracked electronically.
"If you have physician order entry, you can put in computer logic that says you cannot order Coumadin unless there is an INR available in the lab system. That is something we have tested and are in the process of implementing," says Charles Emerman, MD, associate chief of staff in charge of quality and chair of the department of emergency medicine at The MetroHealth System in Cleveland.
Here are some proven strategies for three NPSGs that are especially difficult to monitor, shared by quality professionals:
- Implementing a standardized approach to handoff communications, with an opportunity to ask and respond to questions.
"We can have checkboxes to say that people did this, but I can't always be sitting there listening while people talk to each other," says Emerman.
At University of Pittsburgh Medical Center, the "Ticket to Ride" program is the mechanism used to comply with the handoff goal. The program provides standardization of communication among caregivers at all handoff points, with the goal of reducing serious events related to patient transport and handoffs.
"The program started as a pilot in one hospital and is now being spread throughout our system," says Kathy Hale, director of patient safety. "We monitor compliance through our event reporting system, by investigating and tracking events that occur during patient transport or that are in some way a result of a hand-off."
- Hand hygiene guidelines.
Just as you can't listen to everything staff say when they are handing off a patient, you can't watch everybody washing their hands, says Emerman.
At MetroHealth, spot checks are done by staff to observe hand washing, but this system isn't foolproof, says Emerman. "We have a nice process where everybody takes ownership of watching everybody else wash their hands," he says.
"But it's hard to implement that. It's hard to get a 20-year-old care associate to go up and tell a physician to go back and wash their hands, even though we tell them it's OK to do that. I wish I had the magic bullet for this, but I don't. It won't be a permanent fix. It will be something that you have to constantly monitor."
- Universal Protocol.
At University of Pittsburgh Medical Center, measuring compliance with the Universal Protocol requirements to prevent wrong-site surgeries is a challenge, says Hale.
"To measure accurately, there needs to be an observer to verify that each step in the process took place at the right point in time and that the appropriate staff were involved, rather than just verifying that the appropriate paperwork was completed," says Hale.
At Presbyterian Healthcare, the "timeout" process was analyzed over a one-year period, listing all the elements one should consider just prior to the beginning of a procedure.
"It was determined that there was so much 'noise' imposed over the timeout process," says Swain.
The entire organization, including operating rooms and procedural areas, decided to include only those elements critical to the prevention of wrong-site surgery and other procedural mishaps caused by preparation steps. "It was felt there were other processes and policies in place to manage the antibiotic and consent issues," says Swain.
At UCLA Medical Center, a process was implemented where the orderly coming to move the patient had to verify with the nurse the existence of the order for the procedure.
"Even though doctors were not active participants, they had to be permissive for it to occur," says Thomas Rosenthal, MD, chief medical officer. "They had to be tolerant of the two extra minutes for the handoff to occur correctly, instead of saying, 'I don't want any delays, just get my patient down here.'
"It was difficult to get all those pieces in place, and furthermore, it was difficult to measure whether we were accomplishing anything," adds Rosenthal. "We had to find a way to measure that this handoff was actually occurring. You couldn't have that be self-supported."
A novel program was created where undergraduate students were trained to observe the handoff procedure. The student checks to see that the transporter provides a written document for the nurse, the nurse checks for an order in the chart, and both the transporter and nurse check for two patient identifiers.
"You would think if you are being observed, you would be compliant 100% of the time, but that was not the case," says Rosenthal. "When we started, our compliance was 40%. That confirms for me that people don't always do it perfectly just because they know they are being watched."
Observed compliance with all measures is now greater than 95%, but this took two years to achieve. "For me, that illustrates that asking for a change of this magnitude is not trivial," Rosenthal says.
[For more information, contact:
Charles Emerman, MD, Associate Chief of Staff/Chair, Department of Emergency Medicine, The MetroHealth System, 2500 MetroHealth Drive. Cleveland, OH 44109.
Thomas Rosenthal, MD, Chief Medical Officer, UCLA Medical Center, 10833 Le Conte Ave., Los Angeles, CA 90095. Phone: (310) 825-4686. E-mail: [email protected].]
Some of the Joint Commission's National Patient Safety Goals (NPSGs) are easier to monitor than others, such as reducing the likelihood of harm associated with the use of anticoagulants, which can be tracked electronically.Subscribe Now for Access
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