International Patient Safety Goals (IPSG)

1. International Patient Safety Goals (IPSG)

2. Improving Patient Safetymeans . . . Reducing Medical Errors Reducing Patient Harm

3. Challenges for Patient Safety Leadership • Move toward a more safety-oriented culture • Practice proactive systems analysis & risk reduction • Standardize processes and equipment • Promote effective communication • Ensure adequate and effective staffing • Implement team training for all staff • Encourage and support patient involvement

4. Systems Analysis in Health Care A systematic evaluation of a health care organization’s systems and processes: • To identify vulnerabilities and hazardous conditions that could (and, over time, will) impact patient safety and quality of care. • To focus the redesign of those systems and processes to improve patient safety and quality of care.

5. Implementation of IPSG…. • Represents proactive strategies to reduce risk of medical error and reflect good practices proposed by leading patient safety experts • Incorporating these new tools into our accreditation requirements is a significant step • Organizations taking responsibility for using the IPSG to foster an atmosphere of continuous improvement is even more important

6. JCI 4th Edition International Patient Safety Goals PSG 1 Identify Patients Correctly PSG 2 Improve Effective Communication PSG 3 Improve the Safety of High-Alert Medications PSG 4 Ensure Correct-Site, Correct-Procedure, Correct-Patient Surgery PSG 5 Reduce the Risk of Health Care Associated Infections PSG 6 Reduce the Risk of Patient Harm Resulting from Falls

7. IPSG.1Identify Patients Correctly • A collaborative process is used to develop policies and/or procedures that address the accuracy of patient identification • Use at least two (2) ways to identify a patient: • giving medications • giving blood and blood products • taking blood samples • taking other samples for clinical testing • providing treatment or procedure • The patient’s Room Number cannot be used as an identifier

8. IPSG 2: Improve Effective Communication • The complete VO and TO or test result is written down by the receiver of the order or test result. • Must use a verification “read back” of complete order or test result • The order or test result is confirmed by the individual who gave the order or test result • Policies and procedures support consistent practice verifying the accuracy of verbal and telephone communications

9. IPSG 3: Improve Safety of High Alert Medications • Policies/procedures are developed to address identification, location, labeling and storage of high-alert medications • Policies/procedures are implemented • Concentrated electrolytes are not present in patient care units unless clinically necessary and actions are taken to prevent inadvertent administration • Concentrated electrolytes that are stored in patient care units are clearly labeled and stored in a manner that restricts access

10. Clinical Necessity • Has to be supported by evidence • Is the substance really needed very quickly? • If it is used to dilute, is the diluted solution available?

11. IPSG 4: Ensure Correct-site, Correct-procedure, Correct-patient Surgery • Collaboratively develop a policy/procedure that includes: • Definition of surgery that incorporates at least those procedures that investigate and/or treat diseases and disorders of the human body through cutting removing, altering, or insertion of diagnostic/therapeutic scopes.

12. IPSG 4 Correct Site, Procedure and Patient • Use an instantly recognizable mark for surgical site identification • Involves the patient in the marking process • Involves the full surgical team and is documented just before starting a surgical procedure • Policies/procedures are developed to support uniform process to ensure correct site, procedure, and patient (including medical and dental procedures done in settings other than the operating theater)

13. Checklist or other process to verify: DOCUMENTS SURGERY SITE CORRECT EQUIPMENT PATIENT Functional & Correct PROCEDURE

14. PSG 5: Reduce the Risk of Health Care-Associated Infections • The organization has adopted or adapted currently published and generally accepted hand-hygiene guidelines • Implements an effective hand-hygiene program • Policies/procedures are developed that support continued reduction of health care associated infections Need data to demonstrate effectiveness

15. IPSG 6: Reduce the Risk of Patient Harm resulting from Falls • Implements a process for the initial assessment of patient for fall risk and reassessment of patients when indicated by a change in condition or medications, among others • Measures are implemented to reduce falls risk for those at risk

16. IPSG 6 Reducing Risk of Harm Resulting from Falls • Measures are monitored for results, both successful fall injury reduction and any unintentional related consequences • Policies/procedures support continued reduction of risk of patient harm resulting from falls in the organization

17. Next Presentation Thank You

18. Access to Care andContinuity of Care (ACC)

19. ACC-Five Areas of Focus • Admission to the Organization • Continuity of Care • Discharge, Referral, and Follow-up • Transfer of Patients • Transportation

20. ACC.1 “ADMISSION” of In-Patients & “REGISTRATION” of Out-Patients • Screening at point of first contact • Determine if care can be provided • Diagnostic test are available for decision making-standardized by policy • Patients are informed if any wait or delay and reasons (waiting list)

21. ACC.1.1 Process of Admission or Registration • Policies & Procedures (PP) standardize admission and registration for out-patients and in-patients • PP Admitting emergency patients • PP Holding patients for observation • PP Managing patients when bed space not available

22. ACC.1.1.1 Emergency Patients • Evidence based triage process is used to prioritize patients with immediate needs • Staff are trained use of the triage process • Staff prioritize patients based on urgency of needs • Emergency patients are assessed and stabilized prior to transfer

23. ACC.1.1.2 Needs are Prioritized for In-patients • Screening assessment identifies patient’s needs • Services or units are selected to meet needs based on the assessment: – Preventative – Palliative – Curative – Rehabilitative

24. ACC.1.1.3 Waiting Periods or Delays • In-patients and out-patients are informed of delays • Reason for delay and available alternatives • Documented in the patient medical record • Written policies/procedures

25. ACC.1.2 Information Provided • Patient and Family receive information during the admission process on: • Proposed care • Expected out comes of care • Expected costs • Sufficient information to make knowledgeable decisions

26. ACC.1.3 Reduction of Barriers • Leaders and staffidentify most common barriers for patients • Physical • Language • Cultural • Other • A process is identified and implemented • to overcome or limit identified barriers • to limit impact of barriers on delivery of services

27. ACC.1.4 Criteria for Admission or Transfer to Intensive Care • Admission/transfer criteria established for Intensive and Specialized Units • Criteria are physiologic-based • Appropriate individuals are involved in developing and implementing the criteria • Patients meet the criteria (documented) • Patients are discharged/transferred when they no longer meet criteria

28. ACC.2 Continuity of Patient Care • Leaders design and support continuity (coordination & resources) • Criteria or policies determine transfers within the organization • Continuity and coordination is evident throughout all phases of patient care and to the patient

29. ACC.2.1 Individual Responsible • There is an individual responsible for patient’s care who is • a physician or other person • qualified to assume responsibility for care • identified to the hospital staff • The individual documents the patient plan of care • Transfer from one individual to another is described in policy

30. ACC.3 Referral and Discharge Policy • Policy for the appropriate referral or discharge of patients • Based on patient’s needs for continuing care • The patient’s readiness for discharge • Discharge planning begins early and includes the family as appropriate • Policy guides patients “on pass” for a defined period of time

31. ACC.3.1 Cooperation with Community Practitioners • Discharge planning for both supportiveand continuing medical services • Community providers, organizations and individuals are identified • Appropriate referrals are made (in the patient’s home community whenever possible)

32. ACC.3.2 Discharge Summary • In-patient clinical records contain a discharge summary prepared by a qualified individual • Follow up instructions • Copies are: • In the patient’s medical record • Given to the patient at discharge • Provided to practitioner responsible for continued care • Policy and procedure define discharge summary

33. ACC.3.2.1 Discharge Summary • Prepared at discharge, documented in the patient’s record and contains: • Reason for admission • Significant physical and other findings • Significant diagnoses and co-morbidities • Diagnostic and therapeutic procedures • Significant medication and treatments • Condition at discharge • Discharge medications and all medications to be taken at home • Follow up instructions Continued on next slide…..

34. ACC.3.2 Discharge Summary • Unless contrary to policy, laws, or culture, patients are given a copy • A copy is provided to the practitioner responsible for patient’s continuing or follow-up care

35. ACC.3.3 Out Patient Summary of Continuing Care • Identify which continuing care patients require a summary • Identify how the summary is maintained and who maintains it • Identify format and content of summary • Define what is considered current • Policy for completed summary

36. ACC.3.4 Understandable Follow Up Instructions • Follow up instructions are understandable • Return for follow up care • When to obtain urgent care • Care necessary to patient’s condition

37. ACC.3.5 Against Medical Advice • Process for management and follow up of in-patients and outpatients who leave AMA • Known family physicians are notified • Applicable with local laws and regualtions

38. ACC.4 Transfer Policy • Guiding process for transferring patients to include: • Patient’s need for continuing care • Transfer of responsibility to another provider or setting • Who is responsible during transfer • Situations where transfer is not possible

39. ACC.4.1 Referring and Receiving Organizations • Referring organization determines whether receiving organization can meet patient’s needs • Arrangements (formal or informal) are in place when patients are frequently transferred

40. ACC.4.2 Written Summary • Clinical summary is transferred with patient & includes: • Patient status • Procedures • Other interventions provided • Patient’s continuing care needs

41. ACC.4.3 Monitoring Patients During Transfer • All patients are monitored during direct transfer • Qualifications of the staff member doing the monitoring are appropriate for patient’s condition

42. ACC.4.4 Documentation of Transfer • Documentation includes: • Name of organization and individual agreeing to receive patient • Reason for transfer • Any special conditions related to transfer • Any change of patient’s condition or status during transfer • Any other notes require by the transferring organization

43. ACC.5 Planning Transportation Needs • Assessment of transportation needs when referring patients • Transportation is arranged appropriate to patient needs • Owned transport vehicles meet laws and regulations • Contracted transportation meets patient needs • Appropriate equipment • Monitoring the quality and safety or transportation • Includes a complaint process

44. Next Presentation Thank You

45. Patient and Family Rights (PFR)

46. PFR – Six Areas of Focus • Identify, Protect and Promote Patient Rights • Inform Patients of Their Rights Including Patient’s Family in Decisions • Informed Consent • Research • Organ Donation

47. PFR.1 Processes Support Rights • Leaders • work collaboratively to protect and advance patient and family rights • understand rights as defined in laws and regulations • Staff members are knowledgeable and can explain their responsibilities • Policies and Procedures (PP) guide and support patient and family rights Continued on next slide

48. PFR.1 Process Support Rights • The hospital respects patient rights, and in some cases the rights of patient’s family: • to have the prerogativeto determine what information is provided the family and others, • and under what circumstances.

49. PFR.1.1 Patient’s Values and Beliefs • There is a hospital process to identify and to respect patient values and beliefs and those of the family • Staff members • use the process • provide care respectful of the patient’s values and beliefs

50. PFR.1.1.1 Spiritual Support • There is a process to respond to requests for religious or spiritual support • Process is designed to accommodate: • Routine requests • Complex requests