Leapfrog and National Quality Forum Safety Practices

Leapfrog Hospital Quality and Safety Survey - 2007

National Quality Forum – Quality Indicators

Roswell Park is the only hospital in Western New York that participates in the Leapfrog Hospital Quality and Safety Survey. Hospital participation is important to the patient because it improves quality health care and promotes informed healthcare decision making.

1. Create and sustain a healthcare culture of safety.

Element 1: Leadership structures and systems must be established to ensure that there is organization-wide awareness of patient safety performance gaps, that there is direct accountability of leaders for those gaps, that an adequate investment is made in performance improvement abilities, and that actions are taken to assure the safe care of every patient served

Element 2: Healthcare organizations must measure their culture, provide feedback to the leadership and staff, and undertake interventions that will reduce patient safety risk

Element 3: Healthcare organizations must establish a proactive, systematic, and organization-wide approach to developing team-based care through teamwork training, skill building, and team led performance improvement interventions that reduce preventable harm to patients

Element 4: Healthcare organizations must systematically identify and mitigate patient safety risks and hazards with an integrated approach in order to continuously drive down preventable patient harm.

2. Ask each patient or legal surrogate to “teach back” in his or her own words key information about the proposed treatments or procedures for which he or she is being asked to provide informed consent.

3. Ensure that written documentation of the patient’s preferences for life-sustaining treatments is prominently displayed in his or her chart.

4. Following serious unanticipated outcomes, including those that are clearly caused by systems failures, the patient and, as appropriate, the family should receive timely, transparent, and clear communication concerning what is known about the event.

5. Implement critical components of a well-designed nursing workforce that mutually reinforce patient safeguards, including the following:

a nurse staffing plan with evidence that it is adequately resourced and actively managed and that its effectiveness is regularly evaluated with respect to patient safety;
senior administrative nursing leaders, such as a chief nursing officer, as part of the hospital senior management team;
governance boards and senior administrative leaders that take accountability for reducing patient safety risks related to nurse staffing decisions and the provision of financial resources for nursing services; and
the provision of budget resources to support nursing staff in the ongoing acquisition and maintenance of professional knowledge and skills.

6. Ensure that non-nursing, direct care staffing levels are adequate, that the staff is competent, and that they have had adequate orientation, training, and education to perform their assigned direct care duties.

7. All patients in general intensive care units (ICUs) (both adult and pediatric) should be managed by physicians who have specific training and certification in critical care medicine (“critical care certified”).

8. Ensure that care information is transmitted and appropriately documented in a timely manner and in a clearly understandable form to patients and to all of the patient’s healthcare providers/ professionals, within and between care settings, who need that information in order to provide continued care.

9. For verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person who is receiving the information record and read back the complete order or test result.

10. Implement standardized policies, processes, and systems to ensure the accurate labeling of radiographs, laboratory specimens, or other diagnostic studies so that the right study is labeled for the right patient at the right time.

11. A “discharge plan” must be prepared for each patient at the time of hospital discharge, and a concise discharge summary must be prepared for and relayed to the clinical caregiver accepting responsibility for post-discharge care in a timely manner. Organizations must ensure that there is confirmation of the receipt of the discharge information by the independent licensed practitioner who will assume responsibility for care after discharge.

12. Implement a computerized prescriber order entry (CPOE) system built upon the requisite foundation of re-engineered evidence-based care, an assurance of healthcare organization staff and independent practitioner readiness, and an integrated information technology infrastructure.

13. Standardize a list of “do not use” abbreviations, acronyms, symbols, and dose designations that cannot be used throughout the organization.

14. The healthcare organization must develop, reconcile, and communicate an accurate medication list throughout the continuum of care.

15. Pharmacists should actively participate in medication management systems by, at a minimum, working with other health professionals to select and maintain a formulary of medications chosen for safety and effectiveness, being available for consultation with prescribers on medication ordering, interpretation and review of medication orders, preparation of medications, assurance of the safe storage and availability of medications, dispensing of medications, and administration and monitoring of medications.

16. Standardize methods for the labeling and packaging of medications.

17. Identify all high alert drugs, and establish policies and processes to minimize the risks associated with the use of these drugs. At a minimum, such drugs should include intravenous adrenergic agonists and antagonists, chemotherapy agents, anticoagulants and anti-thrombotics, concentrated parenteral electrolytes, general anesthetics, neuromuscular blockers, insulin and oral hypoglycemics, and opiates.

18. Healthcare organizations should dispense medications, including parenterals, in unit-dose, or, when appropriate, in unit-of-use form, whenever possible.

19. Action should be taken to prevent ventilator-associated pneumonia by implementing ventilator bundle intervention practices.

20. Adhere to effective methods of preventing central venous catheter-associated bloodstream infections, and specify the requirements in explicit policies and procedures.

21. Prevent surgical site infections (SSIs) by implementing four components of care:

appropriate use of antibiotics;
appropriate hair removal;
maintenance of postoperative glucose control for patients undergoing major cardiac surgery; and
establishment of postoperative normothermia for patients undergoing colorectal surgery.

22. Comply with current Centers for Disease Control and Prevention (CDC) Hand Hygiene guidelines.

23. Annually, immunize healthcare workers and patients who should be immunized against influenza.

24. For high-risk elective cardiac procedures or other specified care, patients should be clearly informed of the likely reduced risk of an adverse outcome at treatment facilities that participate in clinical outcomes registries and that minimize the number of surgeons performing those procedures with the strongest volume-outcomes relationship.

25. Implement the Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery™ for all invasive procedures.

26. Evaluate each patient undergoing elective surgery for his or her risk of an acute ischemic perioperative cardiac event, and consider prophylactic treatment with beta blockers for patients who either:

have required beta blockers to control symptoms of angina or have symptomatic arrhythmias or hypertension, or
are at high cardiac risk owing to the finding of ischemia on preoperative testing and are undergoing vascular surgery.

27. Evaluate each patient upon admission, and regularly thereafter, for the risk of developing pressure ulcers. This evaluation should be repeated at regular intervals during care. Clinically appropriate preventive methods should be implemented consequent to this evaluation.

28. Evaluate each patient upon admission, and regularly thereafter, for the risk of developing venous thromboembolism/deep vein thrombosis (VTE/DVT). Utilize clinically appropriate, evidence-based methods of thromboprophylaxis.

29. Every patient on long-term oral anticoagulants should be monitored by a qualified health professional using a careful strategy to ensure the appropriate intensity of supervision.

30. Utilize validated protocols to evaluate patients who are at risk for contrast media-induced renal failure, and utilize a clinically appropriate method for reducing the risk of renal injury based on the patient’s kidney function evaluation.