Reducing Patient Harm

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Reducing Patient Harm

• Pressure Ulcer Reduction Initiative
• January 2009

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HealthInsight

• Private non-profit organization
• Federally-designated Quality Improvement
  Organization (QIO)
• Neutral Convener
• Improve the quality and safety of health care in
  Nevada and Utah

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Workshop Objectives

• Review the Pressure Ulcer (PrU) project
  requirements and plans
• Understand a process for digging deeper a
  systematic approach to problem diagnosis
• Participate in an exercise to further understand
  the factors that contribute to in-house
  development of pressure ulcers
• Discuss your teams plan for future activities

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Project Overview

• Reduce patient harm by improving health care
  processes and systems
• Includes requirements for both nursing homes and
  hospitals using a collaborative model approach

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Why a Collaborative Model?

• Stubborn rate of pressure ulcer prevalence
  persists in Nevada Utah
• Tighter regulations (F314, POA)
• A community issue
• Annually, costs associated with care of PrUs
  exceed 1.3 billion (355 million LTC alone)

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Collaborative Focus

• Prevention!
• Shared learning
• Create a culture of safety
• Resident patient-centered care
• The right care. Every time

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Action Periods

• Action periods between each HealthInsight
  collaborative session
• Facility team ( community team) meetings
• Technical assistance

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Project ComponentsNursing Homes

• MDS data
• Prevalence of High-Risk Long-Stay Residents who
  have Pressure Ulcers
• Realize an 8 relative improvement between
  baseline (January June, 2007) and remeasurement
  (January June, 2010)

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Project ComponentsNursing Homes

• Common Practices
• Treat Stage 3 4 Pressure Ulcers within 24 hours
  of admission?
• Institute preventive measures within 24 hours of
  admission?

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Project ComponentsNursing Homes

• Survey
• Agency for Healthcare Research and Quality (AHRQ)
  Nursing Home Resident Safety Culture Survey
  (http//www.ahrq.gov/qual/hospculture/)
• Baseline 1st quarter 2009 Remeasurement TBD
• Assess culture, track changes, evaluate impact of
  patient safety interventions

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Project ComponentsHospitals

• Medicare Claims Data
• Hospital Acquired Condition/ Present on Admission
  Indicator Initiative
• Realize an 8 relative improvement in incidence
  of Stage III and IV pressure ulcers between
• Baseline (October December, 2008) and
  Remeasurement (January March, 2010)

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Project ComponentsHospitals

• Surveys
• Agency for Healthcare Research and Quality (AHRQ)
  Patient Safety Culture Survey http//www.ahrq.gov
  /qual/hospculture/) or equivalent
• Baseline 1st quarter 2009 Remeasurement TBD
• Assess culture, track changes, evaluate impact of
  patient safety interventions

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Other Project ComponentsHospitals

• Surveys
• Hospital Leadership and Quality Assessment Tool
  (HLQAT) (www.ofmq.com/hlqat)
• Baseline and Remeasurement TBD
• Assess perceptions of hospital board members,
  senior leaders and middle managers about clinical
  quality improvement
• Strong correlation between organizations scoring
  high on HLQAT and being high performing
  organizations on clinical measures

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Other Project Components

• Quarterly Workshops
• Interim Visits (on-site or calls) by
  HealthInsight Staff
• Written Project Updates
• From your team to HealthInsight
• From HealthInsight to your Executive Leadership

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Other Project Components

• Community of Practice, Webinars, Conference Calls
• Listserve pruquality_at_share.healthinsight.org
• FUN!!!

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Today Digging Deeper

• Fault Tree Analysis
• Expand your understanding of possible failure
  paths
• Expand your understanding of failure paths in
  your facility
• Plan Next Steps

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WHY Dig Deeper?

• Diagnose prior to treating
• More effectively link problems with solutions
• Save resources time, staff, energy

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Why Dig Deeper?

• Break down a problem
• It becomes solvable
• Break down a solution
• It becomes attainable

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HealthInsight Contacts

• Jackie Buttaccio, BS, CPHQ
• Nursing Home Liaison
• 702-933-7322, Jbuttaccio_at_healthinsight.org
• Deborah Huber, RN, MHSA
• Hospital Liaison
• 702-933-7305 dhuber_at_healthinsight.org
• www.healthinsight.org

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HealthInsight Contacts

• Juliana Preston, MPA
• Nursing Home Liaison
• 801-892-6625, Jpreston_at_healthinsight.org
• Linda Johnson, MA, BSN, CPHQ
• Hospital Liaison
• 801-892-6677 ljohnson_at_healthinsight.org
• www.healthinsight.org

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• Thank You!
• 9SOW-NV-2008-00-xxx This material was prepared
  by HealthInsight under a contract with the
  Centers for Medicare Medicaid Services (CMS),
  an agency of the U.S. Department of Health and
  Human Services (DHHS). The contents presented do
  not necessarily reflect CMS policy.