SAFE Care Road Map Keeping Patients Safe Across All Areas of Hospital Care

Transcription

1 SAFE Care Road Map Keeping Patients Safe Aross All Areas of Hospital Care SAFE Care 2013 Minnesota Hospital Assoiation

2 The SAFE Care Road Map provides evidene-based reommendations/standards for Minnesota hospitals in the development of a omprehensive patient safety program whih inludes key patient safety praties in the areas of pressure ulers, falls, wrong proedures, adverse drug events, hospital-aquired infetions, perinatal safety, readmissions, ontrolled substanes and overall safety ulture. The road map and aompanying tool kit was made possible with funding through the Centers for Mediare & Mediaid Servies Partnership. We would like to thank the ritial aess hospitals that partiipated in the road map development disussions for sharing their time, expertise and stories whih made the road map and tool kit possible Minnesota Hospital Assoiation

3 Road Map to a SAFE Care Program SAFE Care SAFE Care Speifi Ation(s) Audit Questions Yes No S Safety Teams and Organizational Struture 1) Seure endorsements and resoures for SAFE Care 1a) The faility s leadership endorses implementation and sustainment of the SAFE Care road map praties. 1b) Senior leadership regularly reviews progress toward goals and supports adding resoures as appropriate. 1) The faility has a designated senior leadership sponsor for the SAFE Care road map work. 1d) The faility senior leaders and managers have adopted Justie, Learning and Aountability Priniples, and refer to this model while responding to safety inidents and near misses. 1e) The faility leaders ondut a patient safety ulture survey at least every 1 to 2 years and develop and arry out a plan of ation based on data results. 1f) Senior leaders perform patient safety rounds by interating with diret patient are staff and patients on a regular basis. 1g) Department/unit managers perform patient safety rounds by interating with diret patient are staff and patients, as appliable, on a regular basis. 1h) Department/unit manager safety rounds inlude informal observational auditing and oahing on safety praties suh as repositioning for pressure uler prevention, patient rounding by nursing staff and environmental leaning for environmental servies staff (as appliable to unit/department). 2) Promote patient safety representation/ hampions throughout the faility. 2a) The faility has an interdisiplinary team involved in implementing the road map praties with representation from aross the faility (the team an be an existing team, suh as a patient/quality ommittee). Patient safety hampions/team members/liaisons with lear roles and expetations have been designated from the following areas as appliable: 2b) Physiian/providers 2) Nursing 2d) Nursing Assistants 2e) Infetion Prevention 2f) Safety/Quality 2g) Pharmay 2h) Laboratory 2i) Environmental Servies 2j) Risk Management 2k) Imaging Servies 2l) Human Resoures Page 1 Road Map to a SAFE Care Program 2013 Minnesota Hospital Assoiation

4 SAFE Care Speifi Ation(s) Audit Questions Yes No 2m) Dietary 2n) Operating Room 2o) Rehabilitation Servies 2p) Purhasing 2q) Administration /Senior Leadership 2r) The faility has a designated oordinator(s) for the SAFE Care road map work. 2s) The oordinator(s) has designated time to serve in this oordination funtion. 3) Identify gaps and develop ation plans. The interdisiplinary team: 3a) Reviews the patient safety road map work throughout the year and updates the plan as needed. 3b) Reviews data results at least quarterly and identifies strengths and opportunities. A Aess to Information 1) Trak progress on proess and outome measures. 3) Develops a plan to prioritize and address improvement opportunities. Data Colletion A proess is in plae to ollet and submit to MHA the number of ourrenes for the following at a minimum (as appliable): 1a) Falls 1b) Falls with injury 1) Hospital-aquired pressure ulers inluding most advaned stage of eah uler 1d) Catheter-assoiated urinary trat infetions (CAUTIs) house-wide 1e) Central line-assoiated bloodstream infetions (CLABSIs) 1f) Surgial site infetions (SSIs) aross all proedures 1g) Ventilator-assoiated events (VAEs) 1h) Lab results with INRs > 5 1i) Lab results with blood gluose <40 1j) Naran administrations 1k) Early eletive deliveries not meeting exlusion riteria 1l) Newborn injuries 1m) The faility has a proess in plae (paper or eletroni) for onurrent (real-time) reporting of inidenes by providers and staff. 2) Review and analyze data for improvement opportunities. Data Analysis 2a) A proess is in plae to routinely review and analyze data for proess improvement opportunities/defets. 2b) A proess is in plae to trak progress against established targets e.g., run harts, ontrol harts, dashboards, soreards. 2) A proess is in plae to prioritize and at upon identified issues. Page 2 Road Map to a SAFE Care Program 2013 Minnesota Hospital Assoiation

5 SAFE Care Speifi Ation(s) Audit Questions Yes No 3) Data is shared on a regular basis to promote system-wide learning and transpareny. Data and learnings are shared on a regular basis: 3a) With staff 3b) With leadership 3) With medial staff 3d) With the board(s) 3e) With the publi, e.g., posting progress on falls, hand hygiene. F Faility 1) Leadership establishes Expetations and ommuniates lear expetations. 2) Provide eduation for staff and providers. 3) Establish a strutured ommuniation proess. 3f) A proess is in plae to disuss how, what and when to share safety information in a transparent and aessible manner. 1a) Diret patient are staff (e.g., nursing, physiians, therapies staff) is informed of expetations and performane standards regarding their role in the SAFE Care Road Map work. 1b) Support staff (e.g., environmental servies, supply hain, failities/operations) is informed of expetations and performane standards regarding their role in the patient safety road map work. 1) The faility has a learly defined proess for speaking up and stopping the line if a potential safety issue has been identified by staff. The proess learly outlines: When to stop the line; How to stop the line, e.g. I need larity ; The hain of ommand to follow if not supported in stopping the line; Clear ommuniation to staff from managers and leadership that staff will be supported if they speak up. 2a) Expetations and supporting patient safety road map eduation have been inorporated into new employee orientation. 2b) Ongoing patient safety road map eduation is provided annually. 3a) The faility has strutured ommuniation tools (e.g., Situation, Bakground, Assessment, Reommendation (SBAR); white boards; shift report template; tiket to ride for ommuniation at all levels of the organization. A strutured hand-off proess (e.g., heklist, huddles, bedside shift report) is in plae throughout the organization with speifi elements outlined that must be inluded for hand-offs: 3b) During shift hange 3) Between departments/units 3d) To other failities 3e) A proess is in plae to ommuniate and reeive plans of are to/from long-term are/ swing beds. Page 3 Road Map to a SAFE Care Program 2013 Minnesota Hospital Assoiation

6 E Engagement SAFE Care Speifi Ation(s) Audit Questions Yes No of Patient and Families 1) Eduate and empower patients/families 1a) A proess is in plae to assess and address any barriers to patient/family ability to understand their role in patient safety (e.g., ultural, language, hearing impairment and health literay). 1b) Patients/families are eduated on their role in patient safety and prevention measures they an expet to see from staff (e.g., hand washing, repositioning, patient identifiation). 1) The faility has a proess in plae to eduate staff on the use of teah bak strategies. 1d) A proess is in plae to assess patient /family s level of understanding of the eduation provided (e.g., teah bak). 1e) The faility has a proess in plae to enourage patients and families to speak up if they have patient safety onerns. 1f) A proess is in plae to report bak to patients/ families that have shared a onern. 1g) The faility has a formal proess for patients and families to provide input to the organization on patient safety issues. 1h) The faility has an ative patient and family advisory/ engagement ommittee OR at least one former or urrent patient that serves on a patient safety or quality improvement ommittee or team. Hospital-Aquired Condition Speifi Praties Topi Speifi Ation(s) Audit Questions Yes No Falls Prevent falls and fall related injuries through identifiation and mitigation of patient-speifi risk fators. Currently working on SAFE from FALLS Road Map. (If Yes, move to next setion.) 1a) The faility requires formal falls sreening of all patients within 8 hours of admission for inpatients. The faility requires, AND has a designated plae to doument, re-sreening of patient fall risk: 1b) at least every 24 hours; 1) with transfer between units; 1d) with hange in status/ondition (e.g., post proedure, high-fall risk mediation hange); 1e) post fall. 2) If sreen is positive for fall risk, the faility requires further omprehensive linial assessment of patient s risk fators to link risk fators to appropriate interventions within 8 hours of admission for inpatients. 3) A strutured proess is in plae to identify patients at high-risk for injury from falls (e.g., ABCs: A = Age; B = Bone; C = Coagulation; and s=surgial) within 8 hours of admission for inpatients. 4) The faility has a proess in plae to fous interventions on speifi fall-risk fators rather than on general risk sore. 5) The faility has a proess in plae to fous interventions on speifi fall injury-risk fators. Page 4 Road Map to a SAFE Care Program 2013 Minnesota Hospital Assoiation

7 Topi Speifi Ation(s) Audit Questions Yes No For patients assessed as high-risk for falls, the faility has the following intervention options in plae, at minimum: 6a) Review by physiian and/or pharmaist of highfall risk mediations and timing of mediation administration. 6b) A plan to redue the use of sedative hypnotis for sleep (e.g., Ambien, Ativan and Benadryl). 6) A strutured riteria for identifying patients that should have staff remain within arms reah of patient when toileting. 6d) A strutured staying within arms reah program. 6e) Use of fall injury prevention equipment suh as lowbeds and bedside floor mat. The faility has instituted purposeful bedside rounding for all patients whih inludes: 7a) Strutured proess for onduting rounding, inluding lear expetations of omponents overed during rounds. 7b) Expetations inlude antiipating the are needs of the patient (e.g. mediations due in the next hour, transportation to test or therapy, toileting prior to administration of high-fall risk mediations). 7) Integrating fall prevention heks in rounding (e.g., items are within reah, lear path to bathroom, ords and lines not tripping hazard). 7d) Effetive methods for engaging the patient during bedside rounds. 7e) A roll-out plan for rounding whih inludes small tests of hanges to develop an effetive proess and longterm plan for hard-wiring rounding into work flow. 7f) Involvement of front-line staff in development of rounding proess. 7g) Involvement of nurse managers/leaders in regularly sheduled rounding auditing and oahing. 7h) A standardized auditing tool/proess for onduting rounding audits. 8a) A proess is in plae to ondut a post-fall safety huddle after any fall ours. Pressure Ulers Prevent hospital-aquired pressure ulers through skin inspetion and frequent repositioning. 8b) A proess is in plae to follow-up on any reommendations/orretive ations from safety huddles. Currently working on SAFE Skin Road Map. (If Yes, move to next setion.) 1) The faility requires a omplete patient skin inspetion on admission (ideally within 6 hours) and at least daily. 2) The faility requires the removal or repositioning of devies for patient skin inspetion (e.g., anti-embolism stokings, splints and respiratory equipment). 3) The faility requires patient repositioning at least every 2 hours. 4) If regular repositioning is medially ontraindiated, hourly miro-shifts/off-loads is required (e.g., less than 15 degree shifts, heel and saral off-loads). Page 5 Road Map to a SAFE Care Program 2013 Minnesota Hospital Assoiation

8 Topi Speifi Ation(s) Audit Questions Yes No Safe Proedures Adverse Drug Events Eliminate wrong site proedures through effetive ompletion of the preproedure verifiation and all steps of the Minnesota Time Out for every patient, every invasive proedure, every time. Prevent adverse drug events related to antioagulants, hypoglyemi agents and opioids through appropriate use and monitoring. 5) If patients are not able to be adequately and routinely repositioned, the faility requires immediate and ongoing evaluation for an advaned support surfae with features and omponents suh as low air loss, visous fluid, air fluids, or alternating pressure. 6) The faility requires pressure prevention surfaes for patients with Braden Sore 18. (Note: hek with manufaturer to determine if mattress is speified for pressure uler prevention). 7) The faility requires off-loading/floating of heels any time patients have defiits in sensation, perfusion or mobility throughout the ontinuum of are (e.g., sedation, neuropathy, PVD). 8) A proess is in plae to sreen patients for nutritional risk within 24 hours and request a nutrition onsult as needed. 9) The faility requires the use of leansers speifially designed for the perineal area and moisture barriers for patients with inontinene. Currently working on SAFE SITE Road Map (If Yes, move to next setion.) 1) Senior Leadership has set lear expetations (e.g., establishes and enfores poliy, reinfores pratie during rounds, ommuniates support for staff stopping the line when pratie not followed) for effetive ompletion of the pre-proedure verifiations and eah step of the Time Out proess prior to any invasive proedure. 2) The faility requires that the provider performing the proedure marks the proedure site with their initials using the VA List of Invasive proedures as a minimum guide for proedures requiring a site mark. 3) The faility requires that the 5 steps of the Minnesota Time Out proess are onduted prior to any invasive proedure performed in the faility. 4) The faility has a proess in plae to audit the effetive ompletion of the speifi pre-proedure verifiation and Time Out proess steps for invasive proedures through observational audits. 5) The faility has a proess in plae to address gaps in the pre-proedure and/or Time Out proess when observational audits results show less than 100% adherene to the proess. Currently working on the ADE Road Map. (If Yes, move to next setion.) 1a) The faility has a omprehensive list of look-alike, sound-alike mediations that is routinely updated. 1b) The faility has implemented error-redution strategies in storage, dispensing and administration praties of look-alike, sound-alike mediations (e.g., use of TALLman lettering, separation on shelves and in mediation dispensing abinets). Page 6 Road Map to a SAFE Care Program 2013 Minnesota Hospital Assoiation

9 Topi Speifi Ation(s) Audit Questions Yes No The faility uses Smart infusion pumps for IV mediation administration of all high risk mediations (e.g., opioid PCA, epidural, antithrombotis, platelet inhibitors, insulin) with funtionality employed to: 1) interept and prevent wrong dose errors. 1d) interept and prevent wrong infusion rate errors. Patient Eduation 2a) The faility s patient and family eduation on antioagulants, hypoglyemi agents and opioids inludes, at a minimum: indiation, symptoms for monitoring, dietary issues, drug interations, disease interations, monitoring requirements, duration of therapy and potential adverse effets. 2b) The faility s patient and family mediation eduation uses teah-bak methodology. Antioagulants The faility has standard poliies and praties in plae for managing the initiation and maintenane of antioagulation therapy whih inlude: 3a) The speifi mediation used, e.g., Low Moleular Weight Heparin (LMWH), Warfarin, Unfrationated Heparin (UFH), Vitamin K reversal, Diret thrombin inhibitors. 3b) The ondition being treated. 3) The potential for drug interations. 3d) Colletion of baseline lab values prior to presribing an antioagulant, e.g., INR, platelets, PTT, anti-xa, serum reatinine. 3e) The faility has a protool in plae to determine the need to reverse supra-therapeuti INR values based on key riteria (e.g., the INR value, the presene or absene of bleeding, individual patient situation suh as imminent surgery). 3f) The faility has a renal antioagulant dosing program in plae whih allows a pharmaist or provider to routinely adjust antioagulant doses based on renal funtion. Hypoglyemi Agents The faility has a proess in plae for follow-up after initial hypoglyemi reation ours whih inludes: 4a) The adjustment of insulin dose. 4b) The implementation of standard Blood Gluose monitoring after treatment of hypoglyemia with gluagon or D50 (e.g., 0200 gluose hek, gluose q 1 hr X 3). 4) A plan for ongoing monitoring and dose adjusting to prevent hypoglyemia reourrene. The faility has a proess in plae whih evaluates staff ompetenies related to hypoglyemi agent use inluding: 5a) Hypoglyemia is always onsidered when a patient reeiving insulin has an altered level of onsiousness for no apparent reason. Page 7 Road Map to a SAFE Care Program 2013 Minnesota Hospital Assoiation

10 Topi Speifi Ation(s) Audit Questions Yes No 5b) Hypoglyemia should not be ruled out as a ause of onfusion or altered behavior based on a apillary BG result; a venous lab result should also be obtained. The faility has an established standard order set or protool, approved by medial staff ommittee, in plae for management of hypoglyemi patients whih inludes: 6a) A standard method for management of hypoglyemia, inluding triggers to administer gluose, (e.g., blood gluose value below threshold, signs and symptoms of hypoglyemia) is readily available to aregivers. 6b) Allows nurses to administer hypoglyemia resue agents without prior physiian order. 6) Hypoglyemia resue agents (dextrose, gluagon) are readily aessible throughout the faility where are is provided. Opioids The faility has opioid administration and monitoring pratie guidelines in plae, whih inlude: 7a) Vital signs monitoring, inluding pain, is defined for all linial situations (oral narotis, PCA, epidural, IV injetion). 7b) Continuous pulse oximetry for all patients (exluding end of life patients) reeiving IV infusion narotis. 7) Capnography monitors are used when patient is reeiving supplemental oxygen (exluding end of life patients) and reeiving IV naroti infusion, epidural, PCA, or frequent IV naroti injetions. 7d) Monitor alarms an be heard at the nursing station for pulse oximetry and apnography and annot be turned off. 7e) Monitor alarms automatially default to hospitaldefined thresholds. 7f) Where appropriate, only dose forms that are needed for starting doses are available as over-ride items in automated dispensing abinets (e.g., morphine 2 mg syringes are available but 4 mg syringes are not available on over-ride). Perinatal Safety Prevent perinatal injuries through eliminating Early Eletive Deliveries that do not meet medial exlusion riteria and reduing newborn injury. 7g) The organization has a proess in plae to address how and when to transition opioid therapy from one route to another (e.g., PCA to oral). Currently working on the Perinatal Safety Road Map. (If yes, move to next setion.) 1a) The faility has a hard stop poliy in plae to prevent eletive deliveries less than 39 weeks that do not meet medial exlusion riteria. 1b) The faility has a quality improvement proess in plae to review all deliveries less than 39 weeks for appropriateness of the medial exlusion riteria. The faility provides regular interdisiplinary eduation whih inludes: 2a) Eduation for providers and nurses on Eletroni Fetal Monitoring using the National Institute of Child Health and Human Development (NICHD) ommon language. Page 8 Road Map to a SAFE Care Program 2013 Minnesota Hospital Assoiation

11 Topi Speifi Ation(s) Audit Questions Yes No 2b) Maternal/newborn team risis training on issues suh as: shoulder dystoia, postpartum hemorrhage, emergeny delivery, newborn resusitation and pretransfer stabilization, and hypertensive emergeny. 2) Regular eduational drills for OB emergenies. 3) The faility has standard praties in plae for the appropriate and safe administration of uterotonis relative to uterine ontrations. Health-are assoiated infetions Prevent health areaquired infetions through effetive hand hygiene, environmental leaning and infetion topi-speifi prevention praties. 4) The faility has standard praties in plae for monitoring and doumenting uterine ativity in the medial reord using the National Institute of Child Health and Human Development (NICHD) terminology. Currently working on SAFE from HAI Roadmap. (If Yes, move to next setion) Hand Hygiene 1a) The faility onduts ongoing observational audits to monitor hand hygiene ompliane. 1b) The faility has a proess to analyze and address issues identified through observational audit data. 1) The Justie, Learning and Aountability model is applied when staff or providers are observed not following faility expetations for appropriate hand hygiene. 1d) Patients and families are eduated on their role in preventing infetions and prevention measures, e.g., hand washing, that they an expet to see from health are providers aring for them in the hospital. Environmental Cleaning The faility s prevention strategies for leaning and disinfeting proesses inlude: 2a) Hospital-grade Environmental Protetion Ageny (EPA) -registered germiide is used aording to manufaturers instrutions for routine leaning. 2b) Environmental servies staff is notified of patient rooms requiring speial leaning and disinfetion, suh as for Clostridium diffiile. 2) Chlorine-ontaining or other sporiidal produt/ tehnology is used for daily and terminal environmental disinfetion for all Clostridium diffiile patient rooms and patient are equipment. A proess is in plae for environmental servies leaning staff to: 3a) Reeive eduation on urrent environmental leaning/ disinfetion praties and infetion ontrol at least annually. 3b) Complete a ompeteny evaluation of leaning/ disinfetion praties at least annually. Page 9 Road Map to a SAFE Care Program 2013 Minnesota Hospital Assoiation

12 Topi Speifi Ation(s) Audit Questions Yes No CAUTI 4a) The faility sets lear expetations that indwelling atheter plaement is not appropriate for the following reasons: Inontinene Speimen olletion Diagnosti testing when patient able to void 4b) The faility has a proess in plae for daily review of the atheter neessity and for post surgial atheter removal by end of postoperative day 2. 4) The faility has a standardized pratie, and related eduation, in plae for all providers/staff allowed to insert/remove urinary atheters whih inludes: Appropriate use of atheters Appropriate atheter size Hand hygiene before and after plaement Asepti tehnique and use of sterile equipment Sterile gloves, drape, an antisepti solution for periurethral leaning, and a single paket of lubriant for insertion Identifiation and removal of atheters that are no longer needed Proper maintenane of atheters (e.g., seure atheter, keep below level of the bladder, periurethral leaning, losed drainage system). 4d) The faility has a proess in plae to eduate the patient about their urinary atheter, suh as symptoms of a urinary trat infetion, atheter are, and what the patient an do to help prevent an infetion. Clostridium diffiile (CDI) The faility s ore prevention strategies for CDI inlude: 5a) Nurses are trained to reognize the signs/symptoms of CDI (e.g., Bristol Stool Chart). 5b) Appropriate staff is trained in obtaining speimens for laboratory testing of patients suspeted of having CDI (e.g., ollet unformed stools; no serial testing). 5) Timely ommuniation to the provider that a patient is suspeted of having CDI. 5d) Contat preautions 5e) Hand washing is performed with soap and water rather than, or in addition to, alohol-based hand rub. 5f) Patient and family eduation is provided on CDI inluding: symptoms; what health are providers are doing to prevent an infetion; and what the patient an do to prevent infetion. 5g) Chlorine-ontaining or other sporiidal produt/ tehnology is used for daily and terminal environmental disinfetion for all CDI patient rooms and patient are equipment. 5h) Nursing staff and Environmental Servies staff reeive regular training on appropriate disinfetion and leaning tehniques for CDI. Page 10 Road Map to a SAFE Care Program 2013 Minnesota Hospital Assoiation

13 Topi Speifi Ation(s) Audit Questions Yes No CLABSI (applies to CLABSI house-wide and inludes PICC lines). The faility s ore prevention strategies for entral-line insertion praties inlude: 6a) Optimal atheter site seletion, with avoidane of the femoral vein. 6b) Hand hygiene prior to insertion using an antimirobial soap or alohol-based hand sanitizer 6) Use of maximal staff barrier preautions by all staff diretly involved inluding the use of sterile gloves, sterile gown, ap, mask and large sterile drape. 6d) Use of a hlorhexidine (CHG) and isopropyl alohol skin antisepti (IPA) in a bak-and-forth motion for at least 30 seonds and allowed to dry ompletely. If there is a ontradition due to age or allergy use tinture of iodine, an iodophor or 70% alohol is used. 6e) A proess to ensure entral lines are removed as soon as possible. 6f) The faility performs observational audits on entral line insertions for ompliane with 6a-e. Central Line are and maintenane praties inlude: 7a) Use of sterile gauze, or sterile transparent, semipermeable dressing to over the atheter site. 7b) At least daily review of site for signs and symptoms of infetion. 7) Standardized dressing hange poliies. 7d) Replaement of the dressing if it beomes damp, loosened, or visibly soiled. 7e) Expetations that the atheter or atheter site is not submerged in water (showering should be permitted if preautions an be taken to redue the likelihood of introduing organisms). 7f) Standardized aess poliies (e.g., srub the hub for at least 15 seonds). 7g) Replae administration sets that are ontinuously used, inluding seondary sets and add-on devies, at least every 7 days but no more frequently than every 4 days. 7h) Doumentation of ompletion of the steps for entral line are and maintenane. 7i) The faility s doumentation system (paper or eletroni) is designed to apture suffiient detail to allow for a thorough investigation of the CLABSI. Ventilator-Assoiated Event (VAE) Page 11 Road Map to a SAFE Care Program 2013 Minnesota Hospital Assoiation N/A: The faility s ore prevention strategies for ventilatorassoiated event prevention inlude: 8a) Elevation of the head of bed (HOB) degrees (Over 30 degrees reates a pressure uler risk; patient with HOB > 30 degrees should be plaed on an advaned therapy mattress). 8b) Daily sedative interruption and daily assessment of readiness to extubate. 8) Pepti uler disease prophylaxis. 8d) DVT prophylaxis. 8e) Daily oral are with hlorhexidine.

14 Topi Speifi Ation(s) Audit Questions Yes No 8f) Patient/family eduation related to the ventilator and VAE prevention measures. 8g) Staff eduation related to VAE prevention measures and rationale. 8h) The faility s doumentation system (paper or eletroni) is designed to apture suffiient detail to allow for a thorough investigation of the VAE event. 8i) The faility regularly onduts and douments observational and hart audits for ompliane with 8a-8e). SSI The faility has proesses in plae for appropriate leaning and disinfetion of the surgial environment and equipment whih inludes: 9a) Immediate use sterilization pratie adheres to The Joint Commission reommendations: All visible soil must be removed prior to sterilization. Manufaturers instrutions are available for all instruments; these inlude diretions for the leaning and deontamination proess. Steam sterilization of all types, inluding flashing, must meet parameters (time, temperature, and pressure) speified by both the manufaturer of the sterilizer, the maker of any wrapping or pakaging, and the manufaturer of the surgial instrument. In addition to these instrutions, parametri, hemial and biologial ontrols must be used as designed and direted by their manufaturers. Eah newly sterilized instrument must be arefully proteted to ensure that it is not reontaminated. 9b) Limits for immediate use sterilization to instanes when there are not other viable options (i.e., do not use for onveniene, preferene or when adequate inventory ould eliminate the need for it). 9) Cleaning of the surgial environment is based on guideline(s) by nationally reognized organizations suh as The Joint Commission, AORN and/or HICPAC and inorporates AAMI standards using Spaulding sale definitions. 9d) Training, inluding ompeteny assessments, related to leaning and disinfeting of the surgial environment provided to environmental servies staff at orientation and annually. 9e) Regular evaluation and auditing of the leaning and disinfetion proess. A standardized proess is in plae to prepare the patient s skin and operative site, whih inludes: 9f) Leaving surgial site hair in plae. If hair removal is neessary, razors or depilatory reams that may irritate skin are not used. 9g) The pre-op antisepti agent is based on FDA approval and signifiantly redues miroorganisms and is broad spetrum, fast-ating and has a persistent effet. Consider use of 2% hlorhexidine gluonate (CHG) with isopropyl alohol or iodine povarylex with alohol (70%) unless ontraindiated. Page 12 Road Map to a SAFE Care Program 2013 Minnesota Hospital Assoiation

15 Topi Speifi Ation(s) Audit Questions Yes No 9h) Any skin preparation ontaining alohol must be allowed to dry before beginning surgery due to flammability of the produt. Readmissions 1) Create and implement ommuniation tools (form, report, eletroni tool) that ontain a ommon set of ore and additional elements for eah type of transition. 9i) An evidene-based standardized protool is in plae for the use of prophylati antibiotis. 9j) The faility has a proess in plae to disontinue antibiotis within 24 hours after end of surgery unless otherwise indiated (exeptions: CABG and other ardia surgery). 9k) A baseline blood sugar is established for all patients with known diabetes on the day of surgery. 9l) A proess is in plae to pre-warm the patient s body temperature so that it an be maintained at >96.8 F/ 36 C during surgery. 9m) Post-op SSI prevention eduation is provided to patients and families prior to disharge. 9n) SSI prevention eduation and ompetenies have been inorporated into new employee orientation and annual training for all surgial staff, staff aring for surgial patients, surgeons and other providers. 9o) The OR door is only opened for essential passage of equipment, personnel and patient during surgery. Currently working on SAFE Transitions Road Map. (If Yes, move to next setion) The faility requires, AND has a designated form that ontains, the MHA Core Elements of information for eah appropriate transition setting: 1a) Hospital to other settings. 1b) Other settings to hospital. 1) Emergeny department to hospital and other settings. 2) Comprehensive transition planning. The faility has a proess in plae for regular ommuniations with reeiving failities or next setting of are inluding: 1d) A lear delineation of roles and responsibilities between failities or organizations. 1e) Timelines for ommuniations that allow the reeiving provider to effetively treat the patient and take into aount the patient s linial presentation and the urgeny of the follow-up required. 1f) The format of ommuniation whih inludes one of the following: all, voie mail, fax, or other seure, private, and aessible means inluding mutual aess to an eletroni health reord. The faility has a proess for omprehensive transition planning with the patient and family, that inludes at a minimum, in plain language: 2a) Reason for hospitalization. 2b) Mediations summary. 2) Self are ativities. 2d) Durable medial equipment needs. Page 13 Road Map to a SAFE Care Program 2013 Minnesota Hospital Assoiation

16 Topi Speifi Ation(s) Audit Questions Yes No 2e) Symptom reognition and management. 2f) Coordination and planning for follow-up appointments. 2g) Follow up of results from lab tests or other studies that are pending at disharge. 3) Mediation reoniliation 3a) The faility has a proess to review mediation orders at the time of transition for auray, neessity, potential side effets and/or interations for patients. 3b) The faility has a proess to provide mediation instrution for patients, inluding an assessment of the patient s ability to aurately and reliably take mediations. 4) Care Transition Support 4) The faility has a proess to ensure that patients have a follow-up appointment with their primary are physiian within 5 business days or there is purposeful ontat with the patient within 72 hours, by a team member with knowledge of the patient s history and plan of are. 5) Patient and Family Engagement 5) The faility has a proess to involve patients and aregivers in developing and exeuting the plan of are. Controlled Substane Diversion Prevention 6) Data Organization has a proess in plae to prevent and respond to ontrolled substane diversion 6) The faility has a proess to ontinuously review and trak utilization data related to readmissions to identify avoidable readmissions and opportunities for improvement. Currently working on Controlled Substanes Diversion Road Map (If Yes, move to next setion.) 1a) The organization has designated a ore team involved in developing and overseeing the Controlled Substane (CS) Diversion Prevention Program that inludes prevention, detetion, and investigation. 1b) The organization has a proess to generate and review ontrolled substane data (e.g., ontrolled substane surveillane reports, high-user reports, disposition and Inventory sheets) on at least a monthly basis. 1) The organization proatively ollaborates with loal law enforement to develop a proess to respond to suspeted diversion, inluding ontating loal, state, federal law enforement. 1d) Expetations and supporting eduation have been inorporated into training for all new staff and Liensed Independent Pratitioner (LIP), inluding, at a minimum, awareness training to know the signs of diversion. 1e) The organization ommuniates the expetation that staff speak up when they beome aware of an issue related to CS diversion. Page 14 Road Map to a SAFE Care Program 2013 Minnesota Hospital Assoiation