Bronze and Green Boxes

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Call to Action SAFE SITE
December 4, 2007
Julie ApoldDirector, Patient Safety Minnesota
Hospital Association
www.mnhospitals.org
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Why Are We Here?
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Why Are We Here?

• National and Local Efforts
• Joint Commission Universal Protocol
• SIA Safe Site Surgery Collaborative
• Beginning July 2003, hospitals had to report
  adverse surgical events under Minnesotas adverse
  health care event reporting law.
• Surgery performed on wrong body part
• Surgery performed on wrong patient
• The wrong surgical procedure performed on a
  patient
• Retention of a foreign object
• Death during or immediately after surgery of a
  normal, healthy patient

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Why Are We Here?

• Over past reporting year, saw clusters of wrong
  site events in the OR
• Common root causes
• SIA was seeing similar cases
• Meeting with MDH, MHA and SIA

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AHE Call to Action

• Focus on top four event types
• Pressure Ulcers
• Falls
• Wrong Site, Patient and Procedure
• Retained Objects

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SAFE from FALLS

• SAFE SKIN was kicked-off in February
• SAFE from FALLS began in May
• Similar Structure
• Begin with protocol/best practices
• Development of an implementation road map
• Audit criteria Yes/No Questions
• SAFE Infrastructure
• SKIN, FALLS Patient Care Bundle

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Progress on Calls to Action
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Learnings from Calls-to-Actions

• 1st Step Building Infrastructure
• Getting Teams in Place
• Scheduling meeting time
• Assigning Coordinator
• Carving out time for coordination
• Next Steps
• Firming up PP and tools
• Staff Education
• Team Members
• All involved Staff - Initial and On-going
• Documentation Systems
• Ability to incorporate cues and forcing functions

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SAFE SITE

• SAFE SITE is designed to assist in implementing
  best practices share findings and resources
  across facilities.
• Initial steps review AHE learnings, safe site
  protocol.
• Determine implementation practices for an
  effective SAFE SITE program.
• SAFE Safe Site Program Infrastructure
• SITE Patient Care Bundle

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Surgical Advisory Group

• Sophia Anaya
• Marietta Farris
• Dana Langness
• Mary Jo Harrington

• Shari Bakker
• Terry Voigt
• Larry Asplin
• Kathy Kupner
• Carol Hamlin

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SAFE SITE Baseline Data

• Roadmap contains 54 questions
• Yes Responses By Hospital
• Range 22 - 98 Roadmap elements in place
• Average number of yes responses 60
• By Question
• Range 18 - 95

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Top Barriers to Implementation

• Prioritizing what to do first
• Getting surgeons on board
• No physician champion identified
• Knowledge deficit Time for education
• No clearly designated person accountable for the
  pause belief that the pause isnt really
  necessary
• The number of areas that perform procedures makes
  collaboration difficult
• No enforcement of consequences

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Actions Planned for 1st Quarter

• Identify physician champions
• Partner physician champion with the specialty
  leads
• Form safe site team
• Define roles of each team member
• Develop policies and processes for Safe Site
  including expectations and consequences
• Staff education including physicians
• Observational audits
• Begin piloting briefings

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Toolkit Items

• Road map and tool kit more focus on SAFE
• Full documents available online
• www.mnhospitals.org patient safety
  calls-to-action

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Next Steps

• Complete road map audit
• Complete action steps
• Work on this quarters actions
• Calendar of Events
• List of Conference Call Dates and call-in
  information will distribute
• List of Roadmap Data Submission Due dates
• Answers to previous quarter will be appear only
  need to change any no responses to yes
  responses
• Complete next quarters roadmap by March 28

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Questions??

• Julie Apold
• japold_at_mnhospitals.org