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?