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Patient Safety Initiative (PSI):Hospital Survey Protocol
Russ Forney, PhD, MT(ASCP)
Licensing & Surveys, Aging Division
Wyoming Department of Health
(Photos courtesy of Cinderella Forney)
Sizing Up the Situation
• Adverse events 1 in 3 admissions (2011)• HAIs affect 1 in 20 inpatients• About 1 in 5 Medicare patients
readmitted within 30 days of discharge• 1.8M injuries, $35B in 3 years (08-11)• Survey process has little impact
Partnership for Patients
• P4P: focused on improving patient safety in hospitals
• Reduce HAC = reduce readmissions• Partners: HHS, FDA, CDC, VA, HENs,
QIOs, National and State associations, professional societies
HEAD SCRATCHING…
Patient Safety Initiative (PSI)
• PSI emerged from P4P• CMS S&C initiative• Tools for surveyors & facilities• Focus on infection control, discharge
planning, and QAPI activities
Approaching a Solution
• 4,000 member organizations (“partners”)• Goal: Reduce readmissions• Tools to assist hospitals and surveyors• Common to certification & accreditation
(“substantial equivalent”)• Adopted focus: IC, DC, QAPI
RUSS GOES TO BALTIMORE…
…AND SO DOES PAT
PSI & Pilot Surveys
• Acute Care Hospital survey process• Emphasize 3 CoPs:• QAPI• Discharge planning• Infection Control
• Regulations unchanged, build better surveyors
Initial Impact
• Pilot surveys (field training)• No increase in staffing• Tools guide survey process• Tools identify specific tags• Enhance depth, consistency of surveys
Tool-guided Survey Protocol
• CoP specific survey tools• Underlying CoP not changed• Better identify noncompliance and “best
fit” tag• Target minimum acceptable health &
safety standards
Pilot Survey “Rules”
• Initiate complaint survey (CMS 2802)• No conditions (other than IJ)• One CoP (tool) per survey• Training in the field (OJT)• Share surveyor tools with facilities
A MATTER OF PERSPECTIVE…
The Survey Process
Verify compliance through:• Observation, interview, review• Patient driven protocols• Facility-relevant projects• Hospital-wide processes
Apply the surveyor tools within the existing framework
Wyoming PSI Pilot Surveys
• Mountain View Regional Hospital• 13-16 August: Russ, Pat, Janelle, Linda• Infection control surveyor tool
• Ivinson Memorial Hospital• 20-22 August: Pat, Tony, Karen• Discharge planning surveyor tool
• Lander Regional Hospital• 10-11 September: Russ, Pat, Lori, Larry• QAPI surveyor tool
Infection Control Worksheet
• 5 Modules, 42 pages• 2 surveyors x 2 days• Cover all practices to identify & prevent
HAIs• Follow patients through procedures &
treatments
Infection Control Pilot
• More in-depth investigation than current protocol
• No “experts”, but similar outcomes• Heavily weighted on processes &
monitoring activities• Vertical elements
Discharge Planning Worksheet
• 4 Sections, 23 pages• 2 surveyors x 1-2 days• Cover best practices for discharge
planning & coordination of care• All healthcare members involved
Discharge Planning Pilot
• Planning begins at admission• Ongoing throughout admission• Address patient needs post-discharge• Physician involvement• Results in reduced readmissions
QAPI Worksheet
• 6 Parts, 21 pages• 2 surveyors x 1-2 days• Quantitative assessment (data-driven)• Follow specific projects & activities
through entire life-cycle• Required elements: med errors, inf cont,
transfusions, near-miss/adverse events
QAPI Pilot
• QAPI is relevant to the hospital• Involvement through the ranks• Data as basis for analysis (CDC)• Interventions & ongoing assessment• All programs, units, & services
CMS Update
• 187 pilot surveys, 52 State Agencies• Sep 2011 to Sep 2012• Less P&P, more observations of activity• Sorting out regulation vs best practice• Links surveyors and staff more closely• Continue in Fiscal Year 2013…?
WHO ELSE IS IN THE RIVER…
Wyoming Partners
• Mountain-Pacific Quality Health (QIO)• WY Hospital Association• WY Dept of Health• WY HAI Advisory Group• HAI Coordinator• HLS
• WY ASC Association (IC initiatives)
Contact:Russ Forney, PhD, MT(ASCP)Healthcare Licensing & SurveysAging Division, WY Dept Healthruss.forney@health.wyo.gov307-777-7123
“Preferred” Contact:Patricia (Pat) Prince, RNpat.prince@wyo.gov307-777-7123
QUESTIONS?
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