Our members always strive to give their patients the best care possible. But three years ago the Centers for Medicare and Medicaid (CMS) challenged U.S hospitals to reduce hospital-acquired conditions by 40 percent and hospital readmissions by 20 percent by December 2014.
Ninety-seven WSHA hospitals joined the initiative and pledged to work together to make health care safer, more reliable and less costly – ultimately saving thousands of lives and millions of dollars.
Under the direction of the WSHA Hospital Engagement Network (HEN) our members diligently tested, implemented and shared best practices and innovations for ensuring that no patient would receive harm under their care. Through collaboration and hard work they have transformed processes and practiced transparency with data and results.
CMS has held each of its 26 HENs accountable, requiring monthly, quarterly, and annual reports of their progress. WSHA’s results have been remarkable; in less than three years we have reached or exceeded goals in more than half of the measures resulting not only in thousands of lives saved, but a cost savings of $141 million.
Recently CMS evaluated each of the 26 HENs across the country, assigning points for goals reached as well as specific requirements set forth by the contract. We are pleased to say that WSHA is among the top performing HENs in the nation, achieving 91 points on the CMS Interim Report’s highest bar. The average HEN score was 89. We also achieved extra points in leadership.
“What these numbers mean is that we are making a difference in the lives of patients. The rate of patient harm is the lowest it has ever been according to the Agency for Healthcare Research and Quality. We have babies being born full term who will be healthier, grandparents who are not being readmitted to the hospital and will live to see their grandchildren and even great grandchildren grow, and thousands more who are not experiencing life threatening infections or adverse drug events,” said Carol Wagner, WSHA Senior Vice President for Patient Safety.
New Patient Safety Tools and Resources Available Now!
As our efforts to improve patient safety across the board progress, we are continually adding new tools and resources to our Patient Safety Web pages. Here are some of the more recent pages that feature new tools, guides and videos:
Hospital and Worker Culture of Safety
Safe Patient Handling Bundle
Transforming Culture Toolkit
Executive Rounds Toolkit and Video
Safe Deliveries Roadmap
Labor Management Bundle
Implementation Guide with Tools
Measures Definitions with Resources
100K Children Campaign
Leading Practice Tools
Safe Imaging Toolkit
Updated Warm Handover Guide
Care Transitions Toolkit
Engaging Leadership and Transforming Culture to Improve Safety
Transforming Culture – Effective Leadership for the Delivery of Health Services
Executive Rounds for Safety Toolkit
Executive Rounding Video
Our dynamic, interactive and helpful pages are updated frequently so be sure to check them often. You can find the Partnership for Patients Measures here, LEAPT measures here and general patient safety here. (Rebecca Snyders, RebeccaS@wsha.org)
Joint Commission Issues Alert on Tubing Misconnection Risk
As the health care field transitions to new manufacturing standards for medical tubing connectors, The Joint Commission recently issued an alert containing updated recommendations and strategies to prevent tubing misconnections.
Developed by the International Organization for Standards, the new standards are expected to make tubing misconnections nearly impossible. However, old connectors will remain in the market until they are sold out, leading to potential confusion, according to the Sentinel Event Alert. It urges hospitals, long-term care facilities, home health providers and others that use medical tubing to begin planning for the October transition to the new connectors and remain alert for possible misconnections.
Tubing misconnections are the root cause of too many episodes of patient harm, and The Joint Commission is committed to helping health care organizations prevent them,” said Mark Chassin, M.D., Joint Commission President and CEO. “Organizational leadership is the first line of defense in this transition to the new connectors. Leaders must assume the responsibility for ensuring the safe adoption of the new standards and they must empower their employees to not be afraid to speak up if they discover a problem.” (Amber Theel, AmberT@wsha.org)
WSHA LEAPT Hospitals Making Gains in Clostridium difficile Infection Reduction
Since October 2013, the Washington State Hospital Association and our Leading Edge Advanced Practice Topics (LEAPT) hospitals have reduced the rate of Clostridium difficile infections (CDI) by 20 percent. These gains have been achieved through the hard work of our LEAPT participating hospitals to identify and implement new strategies for preventing the spread of this antibiotic-resistant and potentially deadly bacteria.
Hospitals that have been successful at reducing CDI have implemented the following:
- Intensive focus on staff education and frequent auditing of environmental cleaning.
- Hand hygiene with real-time coaching and feedback to staff.
- Presumptive isolation with enteric contact precautions for patients with diarrhea for 24 hours.
- Patient, physician, family, and staff engagement.
- Judicious use of antibiotics and community outreach.
Antimicrobial Stewardship in all Partnership for Patients Hospitals
Antimicrobial Stewardship (ASP) Initiative kicked-off September 5, 2014. WSHA Partnership for Patients hospitals are joining together to reduce the emergence and spread of resistant bacteria through antimicrobial stewardship – using the right antibiotic the right way at the right time. Hospitals will be working to implement the three tiers of a strong ASP program, reduce Clostridium difficile by 10 percent, and provide powerful comparison data related to antibiotic use.
Basic Tier – Foundation:
- Current antibiogram available for prescriber reference and distributed annually to providers.
- Antimicrobial Stewardship Program (ASP) policy and procedure.
- Physician-supervised (e.g. hospitalist, ID physician) multidisciplinary antimicrobial stewardship committee is in place (or part of a current workgroup) and meets at least quarterly.
- Identified person with allotted time, accountability, and training in ASP.
- Annual training on antimicrobial stewardship provided to staff and providers.
- Report and improve results on days of therapy (DOT) of select antibiotics.
- Develop and engage in a real-time antibiotic review and feedback processes to optimize and monitor use of antibiotics.
Safety for Our Workers
As part of the Leading Edge Advance Practice Topics (LEAPT) initiative, WSHA members are collaborating to make hospitals safer places to work. These tools and resources are on the WSHA Hospital and Worker Culture of Safety webpage.
Nine of our hospitals are engaged in the LEAPT Hospital and Worker Culture of Safety project. This diverse group of hospitals has been working to find innovative ways of promoting a culture of safety in their workplaces and to develop and implement a bundle of best practices.
Successful hospitals have implemented leadership engagement and rounding, safety huddles, and increased communication and awareness about safety.
The results to date are impressive: all nine hospitals have achieved reductions in their injury rates since the beginning of the year and the combined injury rate among all member hospitals was 13 percent lower than in 2013. (Shoshanna Handel, ShoshannaH@wsha.org)
Videos Highlight Health Care Disparity Work
The Institute for Diversity in Health Management, in collaboration with Equity of Care, is featuring video vignettes of health care leaders sharing their ideas on eliminating health care disparities by increasing the collection of race, ethnic and language preference (REaL) data; increasing leadership and workforce diversity; and providing culturally competent care.
Interviewed during “Equity: Moving Beyond Diversity,” the Institute’s 2014 National Leadership and Education Conference, these leaders agree that while hospitals have improved the quality of care for diverse patient populations and increased leadership diversity, more work needs to be done. Click here to view the entire video listing. (Carol Wagner, CarolW@wsha.org)
AHRQ Guide Helps Hospitals Engage Patients and Families in their Health Care
Research shows that when patients are engaged in their health care, safety and quality can improve measurably. To promote stronger engagement, the Agency for Healthcare Research and Quality (AHRQ) developed the Guide to Patient and Family Engagement in Hospital Quality and Safety, a tested, evidence-based resource to help hospitals work as partners with patients and families to improve quality and safety.
Among other information, the free guide includes four specific strategies:
- Working with Patients and Families as Advisors—shows how hospitals can work with patients and family members as advisors at the organizational level.
- Communicating to Improve Quality—helps improve communication among patients, family members, clinicians, and hospital staff from the point of admission.
- Nurse Bedside Shift Report—supports the safe handoff of care between nurses by involving the patient and family in the change-of-shift report for nurses.
- IDEAL Discharge Planning—helps reduce preventable readmissions by engaging patients and family members in the transition from hospital to home.
It also features lessons learned from hospitals that have used the guide. (Carol Wagner, CarolW@wsha.org)