Information Management and Continuity of Care Safe Practices (8-13)

Transcription

1 Information Management and Continuity of Care Safe Practices (8-13) David Bates, MD David Classen, MD Charles Denham, MD Becky Martins October 12, 2007 This Webinar focuses upon the following NQF-EndorsedTM Safe Practices: Safe Practice 8. Ensure that care information is transmitted and appropriately documented, in a timely manner and in a clearly understandable form, to patients and to all of the patient s healthcare providers/professionals, within and between care settings, who need that information in order to provide continued care. Safe Practice 9. For verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person who is receiving the information record and read back the complete order or test result. Safe Practice 10. Implement standardized policies, processes, and systems to ensure the accurate labeling of radiographs, laboratory specimens, or other diagnostic studies so that the right study is labeled for the right patient at the right time. Safe Practice 11. A discharge plan must be prepared for each patient at the time of hospital discharge, and a concise discharge summary must be prepared for and relayed to the clinical caregiver accepting responsibility for post-discharge care in a timely manner. Organizations must ensure that there is confirmation of the receipt of the discharge information by the independent licensed practitioner who will assume the responsibility for care after discharge. Safe Practice 12. Implement a computerized prescriber order entry (CPOE) system built upon the requisite foundation of reengineered evidence-based care, an assurance of healthcare organization staff and independent practitioner readiness, and an integrated information technology infrastructure. Safe Practice 13. Standardize a list of do not use abbreviations, acronyms, symbols, and dose designations that cannot be used throughout the organization TMIT 1

2 NQF Safe Practices for Better Healthcare: A Consensus Report 30 Safe Practices Criteria for Inclusion Specificity Benefit Evidence of Effectiveness Generalization Readiness 2007 TMIT 2

3 NQF Safe Practices Maintenance Committee Safe Practice 2006 Update Process SWOT analysis of each practice Comprehensive literature search Expert technical advisory support from more than 250 experts Participation by The Joint Commission, CMS, and AHRQ Input from hospitals and facility involved in 100,000 Lives Campaign Feedback from the Field - Hospitals that reported publicly through The Leapfrog Group and TMIT National Research Test Bed 2007 TMIT 3

4 Harmonization The Quality Choir 2007 TMIT 4

5 The Patient Our Conductor 2007 TMIT 5

6 2007 TMIT 6

7 7 7

8 Click Here To Register 8 8

9 Click Here To Access Resources From Prior Workshops or Webinars 9 9

10 Click Here To Access Resources From Prior Workshops or Webinars 10 10

11 Click Here To Access Slide Sets, Summary Table of Practices, and Peer-Reviewed Papers 11 11

12 30 Safe Practices Organized into Functional Chapters Creating and Sustaining a Culture of Safety (Chapter 2) Informed Consent, Honoring Patient Wishes, and Disclosure (Chapter 3) Matching Healthcare Needs with Service Delivery Capacity (Chapter 4) Information Management and Continuity of Care (Chapter 5) Medication Management (Chapter 6) of Healthcare-Associated Infections (Chapter 7) Condition- and Site-Specific Practices (Chapter 8) 2007 TMIT 12

13 Expansion Implementation Approaches New Horizons and Areas for Research Outcomes, Structure, Process, and Patient-Centered Measures Setting-specific applicability - Rural Hospitals - Children s Hospitals - Specialty Hospitals Relation of each Safe Practice to other relevant Practices 2007 TMIT 13

14 27 Safe Practices required modification 23 Safe Practices included changes deemed material and will require vote 3 Safe Practices embedded into other related practices Risk of Malnutrition Use of Pneumatic Tourniquets Medication Workspaces 3 New Safe Practices Medication Reconciliation Direct Caregivers Disclosure 2007 TMIT 14

15 Culture SP NQF Report Culture Consent & Disclosure Consent & Disclosure Workforce Information Management & Continuity of Care Medication Management Healthcare-Assoc. Infections Condition- & Site-Specific Practices 2007 TMIT All Rights Reserved 15

16 2007 NQF Report CHAPTER 1: Background Summary, and Set of Safe Practices Structures & Systems Consent & Disclosure Informed Consent Culture Meas., F.B., & Interv. Culture Life-Sustaining Treatment Team Training & Team Interv. Disclosure ID Mitigation Risk & Hazards CHAPTER 2: Creating and Sustaining a Culture of Patient Safety Leadership Structures & Systems Culture Measurement, Feedback, and Interventions Teamwork Training and Team Interventions Identification and Mitigation of Risks and Hazards CHAPTER 3: Informed Consent & Disclosure Informed Consent Life-Sustaining Treatment Disclosure CHAPTERS 2-8 : Practices By Subject Nursing Workforce Workforce Direct Caregivers ICU Care CHAPTER 4: Workforce Nursing Workforce Direct Caregivers ICU Care Information Management & Continuity of Care Labeling Studies Pharmacist Central Role Critical Care Info. Discharge System Medication Management High-Alert Meds. CPOE Med. Recon. Order Read-back Std. Med. Labeling & Pkg. Abbreviations Unit-Dose Medications CHAPTER 5: Information Management & Continuity of Care Critical Care Information Order Read-back Labeling Studies Discharge Systems Safe Adoption of Integrated Clinical Systems including CPOE Abbreviations CHAPTER 6: Medication Management Medication Reconciliation Pharmacist Role Standardized Medication Labeling & Packaging High-Alert Medications Unit-Dose Medications Hand Hygiene Healthcare-Associated Infections Condition- & Site-Specific Practices Press. Ulcer Evidence- Based Ref. Influenza Asp. + VAP Wrong-site Sx Central V. Cath. BSI Anticoag. Therapy Periop. MI 16 DVT/VTE Sx-Site Inf. Contrast Media Use CHAPTER 7: Hospital-Acquired Infections of Aspiration and Ventilator- Associated Pneumonia Central Venous Catheter-Related Blood Stream Infection Surgical-Site Infection Hand Hygiene Influenza CHAPTER 8: Evidence-Based Referrals Wrong-Site, Wrong-Procedure, Wrong-Person Surgery Perioperative Myocardial Infarct/Ischemia Pressure Ulcer DVT/VTE Anticoagulation Therapy Contrast Media-Induced Renal Failure

17 2007 NQF Report Culture Culture SP 1 CHAPTER 2: Creating and Sustaining a Culture of Patient Safety Leadership Structures & Systems Structures Culture Meas, Team Training ID Mitigation & Systems F.B, & Interv. & Team Interv. Risk & Hazards Culture Measurement, Feedback and Interventions CHAPTER 2: Creating and Sustaining a Culture of Teamwork Patient Training and Team Safety Interventions Identification and Mitigation of Risks and Hazards CHAPTER 1: Background Summary and Set of Safe Practices Leadership Structures & Systems Consent & Disclosure Culture Measurement, Feedback and Interventions Informed Life Sustaining Disclosure Consent Treatment Teamwork Training and Team Interventions Identification and Mitigation of Risks and Hazards CHAPTERS 2-8 : Practices By Subject Nursing Workforce Work Force Direct Caregivers ICU Care CHAPTER 3: Informed Consent & Disclosure Informed Consent Life Sustaining Treatment Disclosure CHAPTER 4: Workforce Nursing Workforce Direct Caregivers ICU Care Information Management & Continuity of Care Labeling Studies Pharmacist Central Role Critical Care Info. Discharge System Medication Management High-Alert Meds. CPOE Med. Recon. Order Read-back Std. Med. Labeling & Pkg. Abbreviations Unit-Dose Medications CHAPTER 5: Information Management & Continuity of Care Critical Care Information Order Read-back Labeling Studies Discharge Systems Safe Adoption of Integrated Clinical Systems including CPOE Abbreviations CHAPTER 6: Medication Management Medication Reconciliation Pharmacist Role Standardized Medication Labeling & Packaging High-Alert Medications Unit-Dose Medications Hand Hygiene Hospital-Associated Infections Condition- & Site-Specific Practices Press. Ulcer Evidence- Based Ref. Influenza Asp. + VAP Wrong-site Sx Central V. Cath BSI Anticoag. Therapy Periop. MI 17 DVT/VTE Sx-Site Inf. Contrast Media Use CHAPTER 7: Hospital-Acquired Infections of Aspiration and Ventilator- Associated Pneumonia Central Venous Catheter-Related Blood Stream Infection Surgical-Site Infection Hand Hygiene Influenza CHAPTER 8: Evidence-Based Referrals Wrong-Site, Wrong-Procedure, Wrong-Person Surgery Perioperative Myocardial Infarct/Ischemia Pressure Ulcer DVT/VTE Anticoagulation Therapy Contrast Media-Induced Renal Failure

18 2007 NQF Report Culture SP 1 CHAPTER 1: Background Summary and Set of Safe Practices CHAPTERS 2-8 : Practices By Subject Structures & Systems Consent & Disclosure Information Management & Continuity of Care Labeling Studies Pharmacist Central Role Critical Care Info. Culture Meas., F.B., & Interv. Discharge System Medication Management High-Alert Meds Culture CPOE Med. Recon. Team Training & Team Interv. Order Read-back Std. Med. Labeling & Pkg. ID Mitigation Risk & Hazards ICU Care Abbreviations Unit-Dose Medications CHAPTER 2: Creating and Sustaining a Culture of Patient Safety Leadership Structures & Systems Culture Measurement, Feedback and Interventions Teamwork Training and Team Interventions Identification and Mitigation of Risks and Hazards CHAPTER 3: Informed Consent & Disclosure Informed Life Sustaining Informed Consent Consent Treatment Disclosure Life-Sustaining Treatment CHAPTER 3: Informed Consent & Disclosure Disclosure Informed Consent Work Force Life-Sustaining Treatment Nursing Direct Workforce Caregivers Disclosure CHAPTER 4: Workforce Nursing Workforce Direct Caregivers ICU Care CHAPTER 5: Information Management & Continuity of Care Critical Care Information Order Read-back Labeling Studies Discharge Systems Safe Adoption of Integrated Clinical Systems including CPOE Abbreviations CHAPTER 6: Medication Management Medication Reconciliation Pharmacist Role Standardized Medication Labeling & Packaging High-Alert Medications Unit-Dose Medications Hand Hygiene Hospital-Associated Infections Condition- & Site-Specific Practices Press. Ulcer Evidence- Based Ref. Influenza Asp. + VAP Wrong-site Sx Central V. Cath BSI Anticoag. Therapy Periop. MI 18 DVT/VTE Sx-Site Inf. Contrast Media Use CHAPTER 7: Hospital-Acquired Infections of Aspiration and Ventilator- Associated Pneumonia Central Venous Catheter-Related Blood Stream Infection Surgical-Site Infection Hand Hygiene Influenza CHAPTER 8: Evidence-Based Referrals Wrong-Site, Wrong-Procedure, Wrong-Person Surgery Perioperative Myocardial Infarct/Ischemia Pressure Ulcer DVT/VTE Anticoagulation Therapy Contrast Media-Induced Renal Failure

19 2007 NQF Report Culture Culture SP 1 CHAPTER 1: Background Summary and Set of Safe Practices Structures & Systems Consent & Disclosure Informed Consent Culture Meas., F.B., & Interv. Life Sustaining Treatment Team Training & Team Interv. Disclosure ID Mitigation Risk & Hazards CHAPTER 2: Creating and Sustaining a Culture of Patient Safety Leadership Structures & Systems Culture Measurement, Feedback, and Interventions Teamwork Training and Team Interventions Identification and Mitigation of Risks and Hazards CHAPTER 3: Informed Consent & Disclosure Informed Consent Life-Sustaining Treatment Disclosure CHAPTERS 2-8 : Practices By Subject Force CHAPTER 4: Workforce Direct Nursing Workforce Workforce Caregivers Direct Caregivers ICU Care Information Management & Continuity of Care Labeling Studies Pharmacist Central Role Critical Care Info. Discharge System Medication Management High-Alert Meds. CPOE Med. Recon. Order Read-back Std. Med. Labeling & Pkg. ICU Care Abbreviations Unit-Dose Medications CHAPTER 4: Workforce Nursing Workforce Direct Caregivers ICU Care CHAPTER 5: Information Management & Continuity of Care Critical Care Information Order Read-back Labeling Studies Discharge Systems Safe Adoption of Integrated Clinical Systems including CPOE Abbreviations CHAPTER 6: Medication Management Medication Reconciliation Pharmacist Role Standardized Medication Labeling & Packaging High-Alert Medications Unit-Dose Medications Hand Hygiene Hospital-Associated Infections Condition- & Site-Specific Practices Press. Ulcer Evidence- Based Ref. Influenza Asp. + VAP Wrong-site Sx Central V. Cath. BSI Anticoag. Therapy Periop. MI 19 DVT/VTE Sx-Site Inf. Contrast Media Use CHAPTER 7: Hospital-Acquired Infections of Aspiration and Ventilator- Associated Pneumonia Central Venous Catheter-Related Blood Stream Infection Surgical-Site Infection Hand Hygiene Influenza CHAPTER 8: Evidence-Based Referrals Wrong-Site, Wrong-Procedure, Wrong-Person Surgery Perioperative Myocardial Infarct/Ischemia Pressure Ulcer DVT/VTE Anticoagulation Therapy Contrast Media-Induced Renal Failure

20 2007 NQF Report Culture SP 1 CHAPTER 1: Background Summary and Set of Safe Practices Structures & Systems Culture Meas., F.B., & Interv. Culture Consent & Disclosure Informed Consent Life-Sustaining Treatment Team Training & Team Interv. Disclosure ID Mitigation Risk & Hazards CHAPTER 2: Creating and Sustaining a Culture of Patient Safety Leadership Structures & Systems Culture Measurement, Feedback and Interventions Teamwork Training and Team Interventions Identification and Mitigation of Risks and Hazards CHAPTER 3: Informed Consent & Disclosure Informed Consent Life-Sustaining Treatment Disclosure CHAPTERS 2-8 : Practices By Subject Hand Hygiene Hospital-Associated Infections Influenza Workforce CHAPTER 4: Workforce Nursing Workforce Direct Caregivers Nursing Direct Workforce Caregivers ICU Care ICU Care CHAPTER 5: Information Management & Continuity of Care Critical Care Information Information Management & Continuity of Care Labeling Studies Critical Order Care Info. Read-back Discharge Systems Labeling Discharge CPOE Abbreviations Studies System Safe Adoption of Integrated Clinical Systems including Medication Management CPOE Med Recon. Order Read-back Pharmacist High Alert Std. Med Unit Dose Central Role Meds Labeling & Pkg Medications Abbreviations Asp. + VAP Central V. Cath. BSI Sx-Site Inf. CHAPTER 5: Information Management & Continuity of Care Critical Care Information Order Read-back Labeling Studies Discharge Systems Safe Adoption of Integrated Clinical Systems including CPOE Abbreviations CHAPTER 6: Medication Management Medication Reconciliation Pharmacist Role Standardized Medication Labeling & Packaging High-Alert Medications Unit Dose Medications CHAPTER 7: Hospital-Acquired Infections of Aspiration and Ventilator- Associated Pneumonia Central Venous Catheter Related Blood Stream Infection Surgical-Site Infection Hand Hygiene Influenza Condition- & Site-Specific Practices Press. Ulcer Evidence- Based Ref. Wrong-site Sx Anticoag. Therapy Periop. MI 20 DVT/VTE Contrast Media Use CHAPTER 8: Evidence-Based Referrals Wrong-Site, Wrong-Procedure, Wrong-Person Surgery Perioperative Myocardial Infarct/Ischemia Pressure Ulcer DVT/VTE Anticoagulation Therapy Contrast Media-Induced Renal Failure

21 2007 NQF Report Culture SP 1 CHAPTER 1: Background Summary and Set of Safe Practices Structures & Systems Consent & Disclosure Informed Consent Culture Meas., F.B., & Interv. Culture Life-Sustaining Treatment Team Training & Team Interv. Disclosure ID Mitigation Risk & Hazards CHAPTER 2: Creating and Sustaining a Culture of Patient Safety Leadership Structures & Systems Culture Measurement, Feedback and Interventions Teamwork Training and Team Interventions Identification and Mitigation of Risks and Hazards CHAPTER 3: Informed Consent & Disclosure Informed Consent Life-Sustaining Treatment Disclosure CHAPTERS 2-8 : Practices By Subject Nursing Workforce Workforce Direct Caregivers ICU Care CHAPTER 4: Workforce Nursing Workforce Direct Caregivers ICU Care Information Management & Continuity of Care Hand Hygiene Critical Care Info. Influenza Asp. + VAP Central V. Cath. BSI Order Read-back CHAPTER 6: Medication Labeling Discharge Management CPOE Abbreviations Studies System Pharmacist Role Medication Management Medication Reconciliation Med Recon. High-Alert Medications Pharmacist High Alert Std. Med Unit Dose Central Role Meds & Pkg Medications Standardized Medication Labeling & Packaging Unit-Dose Medications Hospital Acquired Infections Sx-Site Inf. CHAPTER 5: Information Management & Continuity of Care Critical Care Information Order Read-back Labeling Studies Discharge Systems Safe Adoption of Integrated Clinical Systems including CPOE Abbreviations CHAPTER 6: Medication Management Medication Reconciliation Pharmacist Role Standardized Medication Labeling & Packaging High-Alert Medications Unit-Dose Medications CHAPTER 7: Hospital-Acquired Infections of Aspiration and Ventilator- Associated Pneumonia Central Venous Catheter-Related Blood Stream Infection Surgical-Site Infection Hand Hygiene Influenza Condition- & Site-Specific Practices Press. Ulcer Evidence- Based Ref. Wrong-site Sx Anticoag. Therapy Periop. MI 21 DVT/VTE Contrast Media Use CHAPTER 8: Evidence-Based Referrals Wrong-Site, Wrong-Procedure, Wrong-Person Surgery Perioperative Myocardial Infarct/Ischemia Pressure Ulcer DVT/VTE Anticoagulation Therapy Contrast Media-Induced Renal Failure

22 2007 NQF Report Culture SP 1 CHAPTER 1: Background Summary and Set of Safe Practices Structures & Systems Culture Consent & Disclosure Informed Consent Culture Meas., F.B., & Interv. Life-Sustaining Treatment Team Training & Team Interv. Disclosure ID Mitigation Risk & Hazards CHAPTER 2: Creating and Sustaining a Culture of Patient Safety Leadership Structures & Systems Culture Measurement, Feedback and Interventions Teamwork Training and Team Interventions Identification and Mitigation of Risks and Hazards CHAPTER 3: Informed Consent & Disclosure Informed Consent Life-Sustaining Treatment Disclosure CHAPTERS 2-8 : Practices By Subject Nursing Workforce Workforce Direct Caregivers ICU Care CHAPTER 4: Workforce Nursing Workforce Direct Caregivers ICU Care Information Management & Continuity of Care Labeling Studies CHAPTER 7: Hospital-Acquired Infections Hospital Acquired Infections of Aspiration and Ventilator- Associated Pneumonia Asp +VAP Central Venous Catheter-Related Blood Stream Infection Central Venous Catheter-Related Blood Stream Surgical-Site Infection Influenza Central V. Cath Sx Site Inf. Hand Hygiene Hand Hygiene BSI Influenza Condition & Site Specific Practices Press. Ulcer Critical Care Info. Evidence- Based Ref. Discharge System Wrong-site Sx Anticoag. Therapy CPOE Periop. MI 22 Order Read-back Abbreviations CHAPTER 7: Healthcare-Associated Infections Medication Management of Aspiration and Med Recon. Ventilator- Associated Pneumonia Pharmacist High Alert Std. Med Unit Dose Central Role Meds Labeling & Pkg Medications Hand Hygiene Influenza Infection Surgical Site Infection DVT/VTE Contrast Media Use CHAPTER 5: Information Management & Continuity of Care Critical Care Information Order Read-back Labeling Studies Discharge Systems Safe Adoption of Integrated Clinical Systems including CPOE Abbreviations CHAPTER 6: Medication Management Medication Reconciliation Pharmacist Role Standardized Medication Labeling & Packaging High-Alert Medications Unit-Dose Medications CHAPTER 8: Evidence-Based Referrals Wrong-Site, Wrong-Procedure, Wrong-Person Surgery Perioperative Myocardial Infarct/Ischemia Pressure Ulcer DVT/VTE Anticoagulation Therapy Contrast Media-Induced Renal Failure

23 2007 NQF Report Culture SP 1 CHAPTER 1: Background Summary and Set of Safe Practices Structures & Systems Culture Meas., F.B., & Interv. Culture Team Training & Team Interv. Consent & Disclosure Informed Consent Life-Sustaining Treatment Disclosure ID Mitigation Risk & Hazards CHAPTER 2: Creating and Sustaining a Culture of Patient Safety Leadership Structures & Systems Culture Measurement, Feedback and Interventions Teamwork Training and Team Interventions Identification and Mitigation of Risks and Hazards CHAPTER 3: Informed Consent & Disclosure Informed Consent Life-Sustaining Treatment Disclosure CHAPTERS 2-8 : Practices By Subject Nursing Workforce Workforce Direct Caregivers ICU Care CHAPTER 4: Workforce Nursing Workforce Direct Caregivers ICU Care Information Management & Continuity of Care Labeling Studies CHAPTER 7: Hospital-Acquired Infections Hospital Acquired Infections of Aspiration and Ventilator- Associated Pneumonia Asp +VAP Central Venous Catheter-Related Blood Stream Infection Wrong-Site, Wrong-Procedure, Wrong-Person Surgical-Site Infection Influenza Central V. Cath Sx Site Inf. Hand Hygiene Hand Hygiene BSI Influenza Press. Ulcer Critical Care Info. Discharge System Wrong site Sx CPOE Peri-Op MI 23 Order Read-back Abbreviations CHAPTER 8: Condition- Medication or Management Site-Specific Practices Evidence-Based Referrals Med Recon. Anticoagulation Pharmacist Therapy High Alert Std. Med Unit Dose Central Role Meds Labeling & Pkg Medications DVT/VTE Pressure Ulcer Surgery Perioperative Condition Myocardial & Site Specific Infarct/Ischemia Practices Evidence Anticoag DVT/VTE Based Ref. Therapy Contrast Media-Induced Renal Failure Contrast Media Use CHAPTER 5: Information Management & Continuity of Care Critical Care Information Order Read-back Labeling Studies Discharge Systems Safe Adoption of Integrated Clinical Systems including CPOE Abbreviations CHAPTER 6: Medication Management Medication Reconciliation Pharmacist Role Standardized Medication Labeling & Packaging High-Alert Medications Unit-Dose Medications CHAPTER 8: Evidence-Based Referrals Wrong-Site, Wrong-Procedure, Wrong-Person Surgery Perioperative Myocardial Infarct/Ischemia Pressure Ulcer DVT/VTE Anticoagulation Therapy Contrast Media-Induced Renal Failure

24 2006 Proposed NQF Report Culture Culture SP 1 CHAPTER 1: Background Summary and Set of Safe Practices Structures & Systems Consent & Disclosure Informed Consent Culture Meas., F.B., & Interv. Life-Sustaining Treatment Team Training & Team Interv. Disclosure ID Mitigation Risk & Hazards CHAPTER 2: Creating and Sustaining a Culture of Patient Safety Leadership Structures & Systems Culture Measurement, Feedback and Interventions Teamwork Training and Team Interventions Identification and Mitigation of Risks and Hazards CHAPTER 3: Informed Consent & Disclosure Informed Consent Life-Sustaining Treatment Disclosure CHAPTERS 2-8 : Practices By Subject Nursing Workforce Workforce Direct Caregivers ICU Care CHAPTER 4: Workforce Nursing Workforce Direct Caregivers ICU Care Information Management & Continuity of Care Labeling Studies Pharmacist Central Role Critical Care Info. Discharge System Medication Management High-Alert Meds. CPOE Med. Recon. Order Read-back Std. Med. Labeling & Pkg. Abbreviations Unit-Dose Medications CHAPTER 5: Information Management & Continuity of Care Critical Care Information Order Read-back Labeling Studies Discharge Systems Safe Adoption of Integrated Clinical Systems including CPOE Abbreviations CHAPTER 6: Medication Management Medication Reconciliation Pharmacist Role Standardized Medication Labeling & Packaging High-Alert Medications Unit-Dose Medications Hand Hygiene Hospital-Acquired Infections Condition- & Site-Specific Practices Press. Ulcer Evidence- Based Ref. Influenza Asp. + VAP Wrong-site Sx Central V. Cath BSI Anticoag. Therapy Periop. MI 24 DVT/VTE Sx-Site Inf. Contrast Media Use CHAPTER 7: Hospital-Acquired Infections of Aspiration and Ventilator- Associated Pneumonia Central Venous Catheter-Related Blood Stream Infection Surgical-Site Infection Hand Hygiene Influenza CHAPTER 8: Evidence-Based Referrals Wrong-Site, Wrong-Procedure, Wrong-Person Surgery Perioperative Myocardial Infarct/Ischemia Pressure Ulcer DVT/VTE Anticoagulation Therapy Contrast Media-Induced Renal Failure

25 EXECUTIVE SUMMARY OVERVIEW 2004 Weight 2007 Weight CHAPTER 2: Creating and Sustaining A Culture of Patient Safety Practice Element 1: Leadership Structures and Systems Practice Element 2: Culture Survey Measurement and Feedback Practice Element 3: Teamwork & Team interventions 263 (Prior SP 1)* 300 SME Points Spread Over 30 Practices 3 New & 3 Redefined Practice Element 4: Identification & Mitigation of Risks and Hazards 120 CHAPTER 3: Informed Consent and Disclosure Safe Practice 2: Informed Consent (Prior SP 10) Safe Practice 3: Life-Sustaining Treatment (Prior SP 11) EXECUTIVE SUMMARY OVERVIEW 2004 Weight 2007 Weight Safe Practice 4: Disclosure NA 25 CHAPTER 7: of Healthcare-Associated Infections CHAPTER 4: Matching Healthcare Needs With Service Delivery Capacity Safe Practice 5: Nursing Workforce (Prior SP 3) 119 Safe Practice 6: Direct Caregivers NA New Safe Practice 7: ICU Care Leap Safe Practice 19: of Aspiration and VAP (Prior SP 19) Safe Practice 20: CVC BSI (Prior SP 20) Safe Practice 21: Surgical-Site Infection (Prior SP 21) CHAPTER 5: Facilitating Information Transfer and Clear Communication Safe Practice 22: Hand Hygiene (Prior SP 25) Safe Practice 8: Critical Care Information (Prior SP 9) Safe Practice 23: Influenza (Prior SP 26) Safe Practice 9: Order Read-Back (Prior SP 6) Chapter 8: Condition- and Site-Specific Practices Safe Practice 10: Labeling Studies (Prior SP 13) Safe Practice 24: Evidence-Based Referrals Leap 3 Safe Practice 11: Discharge Systems (Prior SP 8) Safe Practice 12: Safe Adoption of CPOE 17 Leap 1 25 Safe Practice 25: Wrong-Site, Wrong-Procedure, Wrong-Person Surgery (Prior SP 14) Safe Practice 13: Abbreviations (Prior SP 7) CHAPTER 6: Improving Patient Safety Through Medication Management Safe Practice 26: Perioperative Myocardial Infarct/Ischemia (Prior SP 15) Safe Practice 14: Medication Reconciliation NA New 35 Safe Practice 27: Pressure Ulcer (Prior SP 16) Safe Practice 15: Pharmacist Role (Prior SP 5) Safe Practice 16: Standardizing Medication Labeling and Packaging (Prior SP 28) Safe Practice 28: DVT/VTE (Prior SP 17) Safe Practice 29: Anticoagulation Therapy (Prior SP 18) Safe Practice 17: High-Alert Medications (Prior SP 29) Safe Practice 18: Unit-Dose Medications (Prior SP 30) Safe Practice 30: Contrast Media-Induced Renal Failure (Prior SP 22) CareLeaders Corp.

26 EXECUTIVE SUMMARY OVERVIEW CHAPTER 2: Creating and Sustaining A Culture of Patient Safety Practice Element 1: Leadership Structures and Systems Practice Element 2: Culture Survey Measurement and Feedback Practice Element 3: Teamwork & Team interventions Practice Element 4: Identification & Mitigation of Risks and Hazards 2004 Weight 263 (Prior SP 1)* 300 SME 2007 Weight What went up or is new? Culture 263 to 300 Disclosure 25 Direct Caregiver - 20 Medication Reconciliation - 35 CHAPTER 3: Informed Consent and Disclosure Safe Practice 2: Informed Consent (Prior SP 10) 9 4 EXECUTIVE SUMMARY OVERVIEW 2004 Weight 2007 Weight Safe Practice 3: Life-Sustaining Treatment (Prior SP 11) 12 4 CHAPTER 7: of Healthcare-Associated Infections Safe Practice 4: Disclosure NA CHAPTER 4: Matching Healthcare Needs With Service Delivery Capacity Safe Practice 5: Nursing Workforce (Prior SP 3) 119 Safe Practice 6: Direct Caregivers NA New Safe Practice 19: of Aspiration and VAP (Prior SP 19) Safe Practice 20: CVC BSI (Prior SP 20) Safe Practice 21: Surgical Site Infection (Prior SP 21) Safe Practice 7: ICU Care Leap 2 Safe Practice 22: Hand Hygiene (Prior SP 25) CHAPTER 5: Facilitating Information Transfer and Clear Communication Safe Practice 8: Critical Care Information (Prior SP 9) 84 Safe Practice 9: Order Read-Back (Prior SP 6) Safe Practice 23: Influenza (Prior SP 26) Chapter 8: Condition- and Site-Specific Practices Safe Practice 10: Labeling Studies (Prior SP 13) Safe Practice 24: Evidence-Based Referrals Leap 3 Safe Practice 11: Discharge Systems (Prior SP 8) Safe Practice 12: Safe Adoption of CPOE 17 Leap 1 25 Safe Practice 25: Wrong-Site, Wrong-Procedure, Wrong- Person Surgery (Prior SP 14) Safe Practice 13: Abbreviations (Prior SP 7) CHAPTER 6: Improving Patient Safety Through Medication Management Safe Practice 26: Perioperative Myocardial Infarct/Ischemia (Prior SP 15) Safe Practice 14: Medication Reconciliation NA New 35 Safe Practice 27: Pressure Ulcer (Prior SP 16) Safe Practice 15: Pharmacist Role (Prior SP 5) Safe Practice 16: Standardizing Medication Labeling and Packaging (Prior SP 28) Safe Practice 28: DVT/VTE (Prior SP 17) Safe Practice 29: Anticoagulation Therapy (Prior SP 18 ) Safe Practice 17: High-Alert Medications (Prior SP 29) Safe Practice 18: Unit-Dose Medications (Prior SP 30) Safe Practice 30: Contrast Media-Induced Renal Failure (Prior SP 22) CareLeaders Corp.

27 2006 Proposed Culture SP NQF 1 Report CHAPTER 1: Background Summary and Set of Safe Practices CHAPTER 5: Improving Patient Safety By Facilitating Information Transfer and Clear Communication Safe Objective 8: To promote accurate and timely communication of information between caregivers regarding patients medical history, diagnostic tests, medications, treatments, and procedure findings. Safe Practice 8: Ensure that care information is transmitted in a timely and clearly understandable form to patients and to all the patients healthcare providers/professionals, within and between care settings, who need that information to provide continued care. Information Management & Continuity of Care Labeling Studies Critical Care Info. Discharge System CPOE 27 Order Read-back Abbreviations Formerly Safe Practice 9 Expanded to incorporate loop closure regarding timely communication to and receipt by the provider of critical test results Expanded to ensure patients have access to their medical records within 24 hours of a written request (by fax, electronic means, patient pick-up) Specific minimum record components including H&P; consultations; test results including lab and imaging (including copies of imaging studies), medication lists, and procedural reports Performance Improvement through gap analysis with reports to the board and senior leadership CHAPTER 5: Information Management & Continuity of Care Critical Care Information Order Read-back Labeling Studies Discharge Systems Safe Adoption of Integrated Clinical Systems including CPOE Abbreviations HARMONIZATION: Safe Practice 8: JCAHO 2006 NPSG 2C; 2D; 2D and 2E (Implementation Expectation); 2E Rationale The White House: Transforming Health Care: The President s Health Information Technology Plan (2004). Massachusetts Coalition for the of Medical Errors Material Changes

28 2006 Proposed Culture SP NQF 1 Report CHAPTER 1: Background Summary and Set of Safe Practices CHAPTER 5: Improving Patient Safety By Facilitating Information Transfer and Clear Communication Safe Objective 9: To promote accurate communication about critical test results, treatments, and procedures. Safe Practice 9: For verbal or telephone orders, or for telephonic reporting of critical test results, verify the complete order or test results by having the person receiving the information record and read-back the complete order or test results. Information Management & Continuity of Care Labeling Studies Critical Care Info. Discharge System CPOE Order Read-back Abbreviations Formerly Safe Practice 6 Alignment and harmonization with JCAHO NPSG Includes read-back of critical test results (in alignment with Safe Practice 8) CHAPTER 5: Information Management & Continuity of Care Critical Care Information Order Read-back Labeling Studies Discharge Systems Safe Adoption of Integrated Clinical Systems including CPOE Abbreviations HARMONIZATION: Safe Practice 9: JCAHO 2006 NPSG 2A JCAHO CAMH 2006 Standard MM.3.20(7). 28 Material Changes

29 2006 Proposed Culture SP NQF 1 Report CHAPTER 1: Background Summary and Set of Safe Practices CHAPTER 5: Improving Patient Safety By Facilitating Information Transfer and Clear Communication Safe Objective 10: To reduce the risk of misinterpretation of radiology, laboratory, and pathology studies due to miscommunication or inaccurate labeling. Safe Practice 10: Implement standardized policies, processes, and systems to ensure accurate labeling of radiographs, laboratory specimens, or other diagnostic studies so that right study is labeled for right patient at the right time. Information Management & Continuity of Care Labeling Studies Critical Care Info. Discharge System CPOE Order Read-back Abbreviations Formerly Safe Practice 13 Expanded to include labeling of laboratory specimens and other diagnostic studies in addition to imaging. Alignment and harmonization with JCAHO NPSG on using two patient identifiers. CHAPTER 5: Information Management & Continuity of Care Critical Care Information Order Read-back Labeling Studies Discharge Systems Safe Adoption of Integrated Clinical Systems including CPOE Abbreviations HARMONIZATION: Safe Practice 10: JCAHO 2006 NPSG 1A; 1A (Rationale); 1A (Implementation Expectations) 29 Material Changes

30 2006 Proposed Culture SP NQF 1 Report CHAPTER 1: Background Summary and Set of Safe Practices CHAPTER 5: Improving Patient Safety By Facilitating Information Transfer and Clear Communication Safe Objective 11: To ensure that effective transfer of clinical information to the patient and ambulatory care providers occurs at the time of discharge from healthcare organizations. Safe Practice 11: A Discharge Plan must be prepared for each patient at the time of hospital discharge, and a concise discharge summary must be prepared for and relayed to the clinical caregiver accepting responsibility for postdischarge care in a timely manner. Organization must ensure that there is confirmation of receipt of the discharge information by the independent licensed practitioner who will assume the responsibility for care after discharge. Information Management & Continuity of Care Labeling Studies Critical Care Info. Discharge System CPOE 30 Order Read-back Abbreviations Formerly Safe Practice 8 Expanded to encompass discharge systems including policies and procedures and the discharge planning process: Medication management practices at discharge Medication reconciliation Discharge information to primary care providers Written discharge summary Provider receipt Information to patients Written discharge plan What to do if condition changes Coordination and planning for follow-up appointments CHAPTER 5: Information Management & Continuity of Care Critical Care Information Order Read-back Labeling Studies Discharge Systems Safe Adoption of Integrated Clinical Systems including CPOE Abbreviations HARMONIZATION: Safe Practice 11: JCAHO CAMH 2006 Standards PC.6.10(3); PC.15.10; PC.15.20(5)(7)(8)(9); PC.15.30; IM.6.10(7); NPSG 8B Material Changes

31 2006 Proposed Culture SP NQF 1 Report CHAPTER 1: Background Summary and Set of Safe Practices CHAPTER 5: Improving Patient Safety By Facilitating Information Transfer and Clear Communication Safe Objective 12: To promote safe use of medications, tests, and procedures through successful implementation of integrated clinical information technologies that reduce preventable harm to patients. Safe Practice 12: Implement a computerized prescriber order entry system built upon the requisite foundation of reengineered evidencebased care, assurance of healthcare organization staff and independent practitioner readiness, and an integrated information technology infrastructure. Information Management & Continuity of Care Labeling Studies Critical Care Info. Discharge System CPOE 31 Order Read-back Abbreviations Readiness for CPOE implementation Importance of integrated information technology infrastructure ahead of CPOE implementation Systematic approach including re-engineering processes Financial and human resource allocations Healthcare staff and physician engagement, readiness, and skills to support CPOE implementation Minimum functionality requirements of CPOE system Alignment with current Leapfrog Group requirements CHAPTER 5: Information Management & Continuity of Care Critical Care Information Order Read-back Labeling Studies Discharge Systems Safe Adoption of Integrated Clinical Systems including CPOE Abbreviations HARMONIZATION: Safe Practice 12: Aligned with Leapfrog Group Material Changes

32 2006 Proposed Culture SP NQF 1 Report CHAPTER 1: Background Summary and Set of Safe Practices CHAPTER 5: Improving Patient Safety By Facilitating Information Transfer and Clear Communication Safe Objective 13: To promote accurate communication about critical test results, treatments, and procedures. Safe Practice 13: Standardize a list of Do Not Use abbreviations, acronyms, symbols, and dose designations that cannot be used throughout the organization. Information Management & Continuity of Care Labeling Studies Critical Care Info. Discharge System CPOE Order Read-back Abbreviations Formerly Safe Practice 7 Alignment and harmonization with JCAHO NPSG ( Do Not Use List) CHAPTER 5: Information Management & Continuity of Care Critical Care Information Order Read-back Labeling Studies Discharge Systems Safe Adoption of Integrated Clinical Systems including CPOE Abbreviations HARMONIZATION: Safe Practice 13: JCAHO 2006 NPSG 2B ISMP List of Error-Prone Abbreviations, Symbols, and Dose Designations 32 Material Changes

33 SP 8: Critical Care Information PRACTICE ADDITIONAL SPECIFICATIONS CHECKLIST Critical Care Information: Ensure that care information is transmitted in a timely and clearly understandable form to all patient s healthcare providers/ professionals who need that information to provide continued care. CLOSURE OF CRITICAL INFORMATION LOOPS Closure of information loops both within and between healthcare organizations and care settings must be addressed. Patients must be provided with timely access to their medical records. Goal is to fully close information loops in a timely manner within and between healthcare organizations and between practitioners in all care settings. PERFORMANCE IMPROVEMENT PROGRAM TO CLOSE CRITICAL INFORMATION LOOPS Organization performance improvement program addresses timely closure of information loops between caregivers and between patients and caregivers and actions taken to close patient safety gaps. Accountability for closing these performance gaps is assigned. Regular reports are provided to the board and senior administrative leadership including risk assessments, at a minimum, of imaging reports, laboratory and pathology reports, and what the organization has defined as critical information. CRITICAL TEST RESULTS AND INFORMATION All values defined as critical by the laboratory must be reports to the responsible licensed practitioner within time frames established by the laboratory in cooperation with nursing and the medical staff. TIMELY AVAILABILITY OF MEDICAL RECORDS TO PATIENTS Organization policies and procedures established for patients rapid access to their medical records including, at a minimum: Medical histories Consultations Laboratory test results Imaging results including copies of imaging studies Medication lists Procedural reports Such records must be made available to patients within 24 hours of a written request that includes appropriate release documentation. Records can be made available by fax, electronic means, or for patients to pick up from the healthcare facility The organization ensures that such processes are adequately resourced, actively managed, and regularly evaluated for their effectiveness

34 Safe Practice #8: Care Information Survey Questions Check all boxes that apply. In regard to timely and understandable communication of patient care information to the patient and their care providers our organization is: Aware of the patient safety performance issue as evidenced by: Within the last 12 months prior to submitting this survey the organization has undertaken an educational meeting for administrative or clinical personnel addressing the area, as supported by meeting documentation/attendance records. Within the last 12 months prior to submitting this survey, the organization completed a thorough literature review, performed an enterprise-wide evaluation of adverse events related to a breakdown in communication of patient care information AND submitted a summary report to administration and governance with recommendations for measurable improvement targets for further action. Accountable to it as evidenced by: our departmental and/or clinical service line managers being accountable for this patient safety area through documented personal performance reviews or personal compensation incentives. our organization having either a Patient Safety Officer or an Administrator who oversees organizational patient safety regularly reporting to the CEO and the Board performance improvement metrics related to this Safe Practice and is directly accountable for this through documented personal performance reviews or personal compensation incentives. Invested in our ability to deal with the issue by: having undertaken staff education/knowledge transfer programs addressing communication of patient information to and between caregivers and caregivers and patients/legal guardians within the constraints of federal and state HIPAA requirements as documented by meeting minutes and attendance records during the 12 months prior to submitting the survey. having invested in skill development programs as documented by meeting minutes and attendance records for such programs and project reports during the 12 months prior to submitting the survey. formally allocating dedicated HR resources to focus on all aspects of this Safe Practice including Additional Specifications including a dedicated budget. Has taken actions to address it by within the last 12 months prior to submitting this survey, having implemented or continuing a pre-established formal performance improvement program (with regular performance measurement and process improvement tracking) addressing this area. having implemented a formal clinical unit-wide, department-wide, or clinical service line-wide performance improvement program (with regular performance measurement and process improvement within the last 12 months) addressing all aspects of this Safe Practice including Additional Specifications. having completed an enterprise-wide formal performance improvement program (with regular performance measurement and tracking process improvement within the last 12 months) addressing all aspects of this Safe Practice including Additional Specifications. 34

35 2007 TMIT 35

36 SP 12: Safe Adoption of Integrated Clinical Information Systems including CPOE Update 11_16_06 PRACTICE ADDITIONAL SPECIFICATIONS CHECKLIST Safe Adoption of Integrated Clinical Systems including CPOE: Implement a computerized prescriber order entry system built upon the requisite foundation of re-engineered evidence-based care, assurance of healthcare organization staff and independent practitioner readiness, and an integrated information technology infrastructure. RISKS AND HAZARDS ASSESSMENT Recognition and identification of performance gaps that must be closed by information systems including standardization of care, high risk points in medication management systems (e.g., point of entry and at medication administration), and risks and hazards of disruptive technologies. Risk assessment is included and documented in the organization s CPOE implementation plan RE-ENGINEERING OF CARE PROCESSES AND WORKFLOW Pharmacists, nurses, and prescribers are key players in re-engineering of care ad workflow Prospective re-engineering of care and workflow issues are identified and documented in the organization s CPOE implementation plan READINESS OF INTEGRATED CLINICAL INFORMATION SYSTEMS Prospective assessment of readiness of clinical information systems are documented as part of the CPOE implementation plan, including, at a minimum: Admit, Discharge, and Transfer Systems (ADR) Laboratory Information System with electronic microbiology output Pharmacy Information System Order Management System Electronic Medication Administration Record System (including patient, staff, and medication ID systems) (emar) Clinical Data Repository with Clinical Decision Support Capability Scheduling Information Systems Radiology Information Systems Clinical Documentation Systems READINESS OF HOSPITAL STAFF AND INDEPENDENT PRACTITIONERS Readiness plan includes documentation of participation by all stakeholders including the board, senior administrative management, frontline caregivers, and independent practitioners. Clinical decision support systems designed to address patient safety risks and coupled to care re-engineering and workflow strategies and plans [Continued on next slide] 36 36

37 SP 12: Safe Adoption of Integrated Clinical Information Systems including CPOE Update 11_16_06 PRACTICE ADDITIONAL SPECIFICATIONS CHECKLIST Safe Adoption of Integrated Clinical Systems including CPOE: Implement a computerized prescriber order entry system built upon the requisite foundation of re-engineered evidence-based care, assurance of healthcare organization staff and independent practitioner readiness, and an integrated information technology infrastructure. CPOE SPECIFICATIONS System facilitates medication reconciliation process. CPOE implemented in an existing electronic health record information system or existing clinical information system bi-directionally and tightly interfaced, at a minimum, with pharmacy, the clinical documentation department (including medication administration record), and the laboratory systems to facilitate review of all orders by all providers. System is linked to prescribing error-prevention software with effective clinical decision support capability. System requires prescribers to document the reasons for any override of an error prevention notice. System enables and facilitates timely display and review of all new orders by a pharmacist before administration of the first dose of the medication, except in cases where a delay would cause harm to the patient. CPOE facilitates review and/or display of all pertinent clinical information about the patient, including allergies, height and weight, medications, imaging, laboratory results and a problem list all in one place. System categorizes medications into therapeutic classes or categories (e.g., penicillin and its derivatives) to facilitate the checking of medications within classes, and retains this information over time. System has capacity to check medication ordered as part of the effective clinical decision support for the following: Dose range Drug dosing Drug frequency Drug-drug interactions Dose adjustment based on laboratory results Excessive cumulative dosing Drug allergies Proper route Therapeutic duplication 37 37

38 SP #12: Safe Adoption of Integrated Clinical Systems (CPOE) OBJECTIVE: To promote safe use of medications, tests, and procedures through successful implementation of integrated clinical information technologies that reduce preventable harm to patients. The Problem: Medical errors related to medication and other clinical ordering errors are common. The majority of such events are preventable. Integrated clinical information technologies offer clear benefits in reducing preventable patient harm and error by standardizing optimal care processes. However, adoption of such innovations may also introduce new risks and hazards. Careful adoption is required with recognition of the critical needs for clinical re-engineering of care processes, especially the ordering and administration of medications, readiness of integrated information systems at the point of care, and readiness of healthcare staff and independent practitioners to successfully and safely adopt new technologies, including Computerized Prescriber Order Entry (CPOE). A systematic approach to developing the foundational elements of evidence-based care re-engineering, assurance of healthcare organization staff and independent practitioner readiness, and foundational components of integrated information technology infrastructure must be established prior to implementation of complex technologies such as CPOE systems. Implementation of CPOE systems may occur with a staged or incremental approach. However, such systems, once implemented, should have certain verifiable functional characteristics. CPOE is literally the capstone to significant transformation but implementation can be disruptive. Implementing CPOE is a complex and challenging undertaking for a number of reasons. First, the changeover to physicians placing electronic orders significantly alters the order management process and thus affects the work flow of physicians, nurses, and others in the institution. Few processes and departments remain untouched, as many changes must occur across departments and disciplines. Second, many hospitals lack prior experience with clinical information systems, which affects how physicians organize and accomplish their work. This translates into the need for an information technology (IT) infrastructure that provides system access for all clinical users wherever it is needed, IT processes that are designed to provide almost instantaneous response to physician entries, training designed specifically for physicians, and system reliability for a mission-critical clinical application. Third, advanced clinical information systems provide organizations with functionality that can standardize clinical practice and guide clinician decision making at the point of care. Each organization must decide to what extent, where, and when it wants to implement these new capabilities. Success in this requires new relationships and a high level of collaboration among the IT organization, clinicians, and executive staff. In some hospitals, implementation of CPOE represents the first time the medical staff has collaborated with other disciplines to reduce variations in care. Use of clinical decision support tools the mechanism for integrating knowledge-based prompting and error checking is new territory for most hospitals. Fourth, it is increasingly clear that CPOE implementation can create new and potentially fatal errors. For the reasons stated, organizations need to develop a detailed information technology plan that is coupled to an organization migration plan that addresses cultural issues and change management. Realistic budgets need to be developed and allocated with both plans in mind such that CPOE implementation is safe, effective, and comprehensive. SAFE PRACTICE 12 Implement a computerized prescriber order entry system built upon the requisite foundation of re-engineered evidence-based care, assurance of healthcare organization staff and independent practitioner readiness, and an integrated information technology infrastructure. 38