Transcript Slide 1

The Patient Safety Officer Executive
Training Course
Leapfrog NQF Safe Practices Program
Charles Denham, M.D
© 2005 TMIT
1
Leapfrog NQF Safe Practices Program
• Leapfrog NQF Leap
• NQF Survey Early Results
• Submitter’s Toolbox
• Research Test Bed
© 2005 TMIT
2
What is Leapfrog?
• Founded in 2000
• More than 150 large health care purchasers
• More than 34 million Americans
• More than $62 billion in health care expenditures
© 2005 TMIT
3
Leapfrog Mission
Trigger giant leaps forward in the safety, quality and
affordability of health care
• Informed health care decisions - Surveys
• High-value health care through P-4-P Programs
• 24 “Roll-Out” Regions to arrive at aggressive but
feasible targets
© 2005 TMIT
4
24 “Roll-Out” Regions
© 2005 TMIT
5
What is the National Quality Forum (NQF)?
• The NQF, a non-profit,
voluntary consensus
standards setting
organization
• Membership represent
both Public and
Private sectors
© 2005 TMIT
6
NQF Member Organizations
NPSF
© 2005 TMIT
7
Safe Practice Background
• “National Quality Forum
Safe Practices for Better
Healthcare: A Consensus
Report” was developed to
help standardize
evidence-based safe
practices of care.
• The Leapfrog NQF Safe
Practices ‘Leap’ is using
these safe practices to
survey hospital
performance
© 2005 TMIT
8
NQF Safe Practices for Better Healthcare:
A Consensus Report
• 30 Safe Practices
Criteria for Inclusion
• Specificity
• Benefit
• Evidence of
Effectiveness
• Generalization
• Readiness
© 2005 TMIT
9
The Leapfrog NQF Safe Practices ‘Leap #4’
• NQF endorsed 30 high-priority Safe Practices to
be universally applied in relevant clinical care
settings
• Includes Leapfrog’s initial 3 safe practices
• Leapfrog will now assess hospitals’ progress
on the remaining 27 safe practices
© 2005 TMIT
10
Development of this New Survey
• Survey Tool developed by Texas Medical
Institute of Technology (TMIT)
• 27 practices weighted according to patient
safety impact, combined into a single score
(1,000)
• Relative ranking compared to other
hospitals - placed into quartiles
© 2005 TMIT
11
© 2004 TMIT
12
TMIT
© 2004 TMIT
13
TMIT
© 2004 TMIT
14
TMIT
27 NQF Safe Practices Weighting Results
Enterprise-wide System
#
Practice
Final Weighting out of 1,000 points
1
Create Safety Culture
263
3
Ensure Adequate Nursing Workforce
119
SUBTOTAL
382
Enterprise-wide Process
6
Verbal Order Readback
36
7
Standardized Abbrev./Doses
17
8
No Pt Care Summaries from Memory
17
9
Pt Care Info/Orders to all Providers
84
SUBTOTAL
TOTAL ENTERPRISE-WIDE
Clinical Care Setting or Function Specific
1,000 Points Applied to
27 Practices
Weighted Individually
Hospitals Nationally
Ranked
154
536
5
Pharmacist Active in Med Use
10
Pt Readback of Informed Consent
11
Document Resusc./End of Life/ Directives
13
Prevention of Mislabeled Radiographs
14
Wrong-site/Wrong-patient Prevention
15
Prophylactic Beta Blockers for Elective Surgery
16
Pressure Ulcer Prevention
17
DVT/VTE- Risk Assessment & Prevention
27
18
Anticoagulation Services
39
19
Aspiration Prevention
24
20
Central Venous Line Sepsis Prevention
33
21
Surgical Site Infection/AB Prophylaxis
37
22
Contrast-induced Renal Failure Protocol
12
23
Malnutrition Prevention
12
24
Tourniquet—Ischemia/Thrombosis Prevention
9
25
Hand Washing
33
26
Flu Vaccination for HC Workers
11
27
Optimize Medication Workspaces
7
28
Optimize Med. Storage/Pkg/Labeling
22
29
I.D. High Alert Medications
21
30
Med. Unit Dosing/Unit-of-Use Dispensing
29
SUBTOTAL
© 2003 TMIT Leapfrog Survey 1.0.
32
9
12
16
30
23
28
465
15
11.17.03 1600 CT
27 NQF Safe Practices Weighting Results
Enterprise-wide System
#
Practice
Final Weighting out of 1,000 points
1
Create Safety Culture
263
3
Ensure Adequate Nursing Workforce
119
SUBTOTAL
382
Enterprise-wide Process
6
Verbal Order Readback
36
7
Standardized Abbrev./Doses
17
8
No Pt Care Summaries from Memory
17
9
Pt Care Info/Orders to all Providers
84
SUBTOTAL
154
TOTAL ENTERPRISE-WIDE
536
© 2003 TMIT Leapfrog Survey 1.0.
16
11.17.03 1600 CT
27 NQF Safe Practices Weighting Results
Clinical Care Setting or Function Specific
5
Pharmacist Active in Med Use
32
10
Pt Readback of Informed Consent
9
11
Document Resusc./End of Life/ Directives
12
13
Prevention of Mislabeled Radiographs
16
14
Wrong-site/Wrong-patient Prevention
30
15
Prophylactic Beta Blockers for Elective Surgery
23
16
Pressure Ulcer Prevention
28
17
DVT/VTE- Risk Assessment & Prevention
27
18
Anticoagulation Services
39
19
Aspiration Prevention
24
20
Central Venous Line Sepsis Prevention
33
© 2003 TMIT Leapfrog Survey 1.0.
17
11.17.03 1600 CT
27 NQF Safe Practices Weighting Results
Clinical Care Setting or Function Specific
21
Surgical Site Infection/AB Prophylaxis
37
22
Contrast-induced Renal Failure Protocol
12
23
Malnutrition Prevention
12
24
Tourniquet—Ischemia/Thrombosis Prevention
9
25
Hand Washing
33
26
Flu Vaccination for HC Workers
11
27
Optimize Medication Workspaces
7
28
Optimize Med. Storage/Pkg/Labeling
22
29
I.D. High Alert Medications
21
30
Med. Unit Dosing/Unit-of-Use Dispensing
29
SUBTOTAL
© 2003 TMIT Leapfrog Survey 1.0.
465
18
11.17.03 1600 CT
What Guiding Principles were used to design the 1.0 Survey Questions?
1. Compliment the NQF Safe Practices Report (May 2003): The survey,
weighting system, and ranking system designs are explicitly tied to the problem
areas and practices defined by the NQF report. Recognizing the challenges of
tying standards, measures, or practices to a report that is written at a snapshot
in time, the survey, weighting, and ranking systems take into account that new
evidence and refinement of performance improvement methods are being
generated all the time. Patient safety is an emerging science and is constantly
evolving. Therefore, the guiding principles included focus on the excellent list of
safety problems being targeted by NQF practices and apply the “4 A
Framework” below. The “4 A Framework” provides real flexibility of interpretation
and provides a means of providing partial credit for partial progress and partial
credit for commitment to progress. Although the survey will undergo refinement
through public review and optimization by our subject matter experts, the design
will be kept intact in order to make the survey fair and reasonable. The goal is to
neutralize the challenges of explicitly tying questions to specific language of
practices that are evolving while staying well within the scope of the NQF report.
2. Partial Credit for Partial Progress: The questions were designed using a
“select any that apply” response giving hospitals numerous opportunities for
partial credit. Once significant public input is provided, a set of FAQs will be
provided for each question to assure that respondents will have clarity regarding
what will qualify for credit on a question specific basis.
3. Partial Credit for Commitment: Many of the questions provide partial credit to
organizations that make substantial commitment to get started. This will help
those that may be “behind the safety curve”. The intent is to provide a clear
roadmap to organizations that have heretofore not prioritized safety. These
questions are also intended to provide fairness in areas where patient safety
issues have not been well publicized.
4. Systematic Application of 4A Framework : The 4A framework recognizes the
sequential and interdependent nature of awareness of our performance
opportunities, accountability of leadership, the ability to employ practices, and
measurable action towards closing performance gaps. This “4A Framework”
(updated from a 3 A framework published by C. Denham in 2001) was used as
an organizational structure to allow systematic customization of survey
questions.
 Awareness: Clearly, the leaders of an organization must be aware of
performance problems before they can make any impact on them. The
concept of THE problem or performance opportunity addresses the
awareness by hospitals that there is evidence to support a common
problem across all hospitals. The concept of OUR problem addresses
awareness of the frequency and severity of adverse events to our patient
population within our organization and recognition of the impact that
practices or performance improvement methods can have on those
adverse events. Awareness of THE performance opportunities and OUR
performance opportunities are addressed in a relatively standardized
manner in each survey question, however they were customized to each
problem depending on the current state of awareness in the community.
1.
© 2005 TMIT
 Accountability: A critical success factor to patient safety is
accountability of the leadership to performance. Whether the
mechanisms of personal performance reviews or performance
compensation incentives are used, sustained gains in patient safety
frequently do not occur without personal accountability of the leaders.
This issue was addressed in a relatively standardized way throughout
the survey, however the questions were fine tuned to the scope or
care setting addressed by the practice.
 Ability: An organization may be aware of THE problem – a
performance gap common to most hospitals. In fact they may be
aware of OUR problem (their own) with clear evidence of frequency
and severity of adverse events in their own patient population. They
may even have awareness of the impact of a given practice, however
if they do not invest in education or skill development and more
importantly allocate real protected staff time and dollars to a given
problem, the impact on safety is modest at best. Adding a patient
safety responsibility to an already overloaded employee without
carving out the time and providing them the necessary financial
resources to make an impact sends a clear message to the
organization. The “ability” related survey questions employ a
graduated set of investment levels ranging from investment in
education, skill development (training regarding the application of
practices or performance improvement methods), dedicated HR, and
dedicated line item budget allocations.
 Actions: Action activities were tied to the NQF cited best practices
language as appropriate. Where there have been great strides in best
practices, the survey questions provide latitude for activities
deserving credit. A set of FAQs will be tied to each survey question
that will provide guidance as to what activities may qualify for credit,
especially if certain developments in patient safety have been
substantiated in the literature after publication of the NQF report.
Performance Improvement programs and project actions were given
high emphasis, as such, these programs will require thorough
literature reviews and examination of readily available practices be
undertaken. Such initiatives would include but not limited to the NQF
practices especially if there were new high impact actions that target
the problems listed in the NQF report. Far more important than
attestations of compliance to procedures, policies, and protocols are
ongoing programs that have regular measurement and process
improvement elements.
5. Sensitivity to use of the word “Problem”: Risk managers at hospital
organizations have expressed concern over the use of the word “problem”,
therefore wherever possible the term “performance opportunity” was used in
the survey in place of the word “problem”. That is not to say the word
problem is not used appropriately in the NQF report. It is.
Compliment the NQF Safe Practices Report (May 2003):
•
The survey, weighting system, and ranking system designs are
explicitly tied to the problem areas and practices defined by the
NQF report.
•
Recognizing the challenges of tying standards, measures, or
practices to a report that is written at a snapshot in time, the
survey, weighting, and ranking systems take into account
that new evidence and refinement of performance
improvement methods are being generated all the time.
•
Patient safety is an emerging science and is constantly evolving.
The goal is to neutralize the challenges of explicitly tying
questions to specific language of practices that are
evolving while staying well within the scope of the NQF
report.
19
What Guiding Principles were used to design the 1.0 Survey Questions?
1. Compliment the NQF Safe Practices Report (May 2003): The survey,
weighting system, and ranking system designs are explicitly tied to the problem
areas and practices defined by the NQF report. Recognizing the challenges of
tying standards, measures, or practices to a report that is written at a snapshot
in time, the survey, weighting, and ranking systems take into account that new
evidence and refinement of performance improvement methods are being
generated all the time. Patient safety is an emerging science and is constantly
evolving. Therefore, the guiding principles included focus on the excellent list of
safety problems being targeted by NQF practices and apply the “4 A
Framework” below. The “4 A Framework” provides real flexibility of interpretation
and provides a means of providing partial credit for partial progress and partial
credit for commitment to progress. Although the survey will undergo refinement
through public review and optimization by our subject matter experts, the design
will be kept intact in order to make the survey fair and reasonable. The goal is to
neutralize the challenges of explicitly tying questions to specific language of
practices that are evolving while staying well within the scope of the NQF report.
2. Partial Credit for Partial Progress: The questions were designed using a
“select any that apply” response giving hospitals numerous opportunities for
partial credit. Once significant public input is provided, a set of FAQs will be
provided for each question to assure that respondents will have clarity regarding
what will qualify for credit on a question specific basis.
3. Partial Credit for Commitment: Many of the questions provide partial credit to
organizations that make substantial commitment to get started. This will help
those that may be “behind the safety curve”. The intent is to provide a clear
roadmap to organizations that have heretofore not prioritized safety. These
questions are also intended to provide fairness in areas where patient safety
issues have not been well publicized.
4. Systematic Application of 4A Framework : The 4A framework recognizes the
sequential and interdependent nature of awareness of our performance
opportunities, accountability of leadership, the ability to employ practices, and
measurable action towards closing performance gaps. This “4A Framework”
(updated from a 3 A framework published by C. Denham in 2001) was used as
an organizational structure to allow systematic customization of survey
questions.
 Awareness: Clearly, the leaders of an organization must be aware of
performance problems before they can make any impact on them. The
concept of THE problem or performance opportunity addresses the
awareness by hospitals that there is evidence to support a common
problem across all hospitals. The concept of OUR problem addresses
awareness of the frequency and severity of adverse events to our patient
population within our organization and recognition of the impact that
practices or performance improvement methods can have on those
adverse events. Awareness of THE performance opportunities and OUR
performance opportunities are addressed in a relatively standardized
manner in each survey question, however they were customized to each
problem depending on the current state of awareness in the community.
© 2005 TMIT
 Accountability: A critical success factor to patient safety is
accountability of the leadership to performance. Whether the
mechanisms of personal performance reviews or performance
compensation incentives are used, sustained gains in patient safety
frequently do not occur without personal accountability of the leaders.
This issue was addressed in a relatively standardized way throughout
the survey, however the questions were fine tuned to the scope or
care setting addressed by the practice.
 Ability: An organization may be aware of THE problem – a
performance gap common to most hospitals. In fact they may be
aware of OUR problem (their own) with clear evidence of frequency
and severity of adverse events in their own patient population. They
may even have awareness of the impact of a given practice, however
if they do not invest in education or skill development and more
importantly allocate real protected staff time and dollars to a given
problem, the impact on safety is modest at best. Adding a patient
safety responsibility to an already overloaded employee without
carving out the time and providing them the necessary financial
resources to make an impact sends a clear message to the
organization. The “ability” related survey questions employ a
graduated set of investment levels ranging from investment in
education, skill development (training regarding the application of
practices or performance improvement methods), dedicated HR, and
dedicated line item budget allocations.
 Actions: Action activities were tied to the NQF cited best practices
language as appropriate. Where there have been great strides in best
practices, the survey questions provide latitude for activities
deserving credit. A set of FAQs will be tied to each survey question
that will provide guidance as to what activities may qualify for credit,
especially if certain developments in patient safety have been
substantiated in the literature after publication of the NQF report.
Performance Improvement programs and project actions were given
high emphasis, as such, these programs will require thorough
literature reviews and examination of readily available practices be
undertaken. Such initiatives would include but not limited to the NQF
practices especially if there were new high impact actions that target
the problems listed in the NQF report. Far more important than
attestations of compliance to procedures, policies, and protocols are
ongoing programs that have regular measurement and process
improvement elements.
5. Sensitivity to use of the word “Problem”: Risk managers at hospital
organizations have expressed concern over the use of the word “problem”,
therefore wherever possible the term “performance opportunity” was used in
the survey in place of the word “problem”. That is not to say the word
problem is not used appropriately in the NQF report. It is.
2.
Partial Credit for Partial Progress:
•
The questions were designed using a “select any that apply”
response giving hospitals numerous opportunities for
partial credit. Once significant public input is provided, a set of
FAQs will be provided for each question to assure that
respondents will have clarity regarding what will qualify for credit
on a question specific basis.
3.
Partial Credit for Commitment:
•
Many of the questions provide partial credit to organizations
that make substantial commitment to get started. This will
help those that may be “behind the safety curve”. The intent is to
provide a clear roadmap to organizations that have heretofore
not prioritized safety. These questions are also intended to
provide fairness in areas where patient safety issues have not
been well publicized.
20
What Guiding Principles were used to design the 1.0 Survey Questions?
1. Compliment the NQF Safe Practices Report (May 2003): The survey,
weighting system, and ranking system designs are explicitly tied to the problem
areas and practices defined by the NQF report. Recognizing the challenges of
tying standards, measures, or practices to a report that is written at a snapshot
in time, the survey, weighting, and ranking systems take into account that new
evidence and refinement of performance improvement methods are being
generated all the time. Patient safety is an emerging science and is constantly
evolving. Therefore, the guiding principles included focus on the excellent list of
safety problems being targeted by NQF practices and apply the “4 A
Framework” below. The “4 A Framework” provides real flexibility of interpretation
and provides a means of providing partial credit for partial progress and partial
credit for commitment to progress. Although the survey will undergo refinement
through public review and optimization by our subject matter experts, the design
will be kept intact in order to make the survey fair and reasonable. The goal is to
neutralize the challenges of explicitly tying questions to specific language of
practices that are evolving while staying well within the scope of the NQF report.
2. Partial Credit for Partial Progress: The questions were designed using a
“select any that apply” response giving hospitals numerous opportunities for
partial credit. Once significant public input is provided, a set of FAQs will be
provided for each question to assure that respondents will have clarity regarding
what will qualify for credit on a question specific basis.
3. Partial Credit for Commitment: Many of the questions provide partial credit to
organizations that make substantial commitment to get started. This will help
those that may be “behind the safety curve”. The intent is to provide a clear
roadmap to organizations that have heretofore not prioritized safety. These
questions are also intended to provide fairness in areas where patient safety
issues have not been well publicized.
4. Systematic Application of 4A Framework : The 4A framework recognizes the
sequential and interdependent nature of awareness of our performance
opportunities, accountability of leadership, the ability to employ practices, and
measurable action towards closing performance gaps. This “4A Framework”
(updated from a 3 A framework published by C. Denham in 2001) was used as
an organizational structure to allow systematic customization of survey
questions.
 Awareness: Clearly, the leaders of an organization must be aware of
performance problems before they can make any impact on them. The
concept of THE problem or performance opportunity addresses the
awareness by hospitals that there is evidence to support a common
problem across all hospitals. The concept of OUR problem addresses
awareness of the frequency and severity of adverse events to our patient
population within our organization and recognition of the impact that
practices or performance improvement methods can have on those
adverse events. Awareness of THE performance opportunities and OUR
performance opportunities are addressed in a relatively standardized
manner in each survey question, however they were customized to each
problem depending on the current state of awareness in the community.
4.
Systematic Application of 4 A Framework:
•
© 2005 TMIT
 Accountability: A critical success factor to patient safety is
accountability of the leadership to performance. Whether the
mechanisms of personal performance reviews or performance
compensation incentives are used, sustained gains in patient safety
frequently do not occur without personal accountability of the leaders.
This issue was addressed in a relatively standardized way throughout
the survey, however the questions were fine tuned to the scope or
care setting addressed by the practice.
 Ability: An organization may be aware of THE problem – a
performance gap common to most hospitals. In fact they may be
aware of OUR problem (their own) with clear evidence of frequency
and severity of adverse events in their own patient population. They
may even have awareness of the impact of a given practice, however
if they do not invest in education or skill development and more
importantly allocate real protected staff time and dollars to a given
problem, the impact on safety is modest at best. Adding a patient
safety responsibility to an already overloaded employee without
carving out the time and providing them the necessary financial
resources to make an impact sends a clear message to the
organization. The “ability” related survey questions employ a
graduated set of investment levels ranging from investment in
education, skill development (training regarding the application of
practices or performance improvement methods), dedicated HR, and
dedicated line item budget allocations.
 Actions: Action activities were tied to the NQF cited best practices
language as appropriate. Where there have been great strides in best
practices, the survey questions provide latitude for activities
deserving credit. A set of FAQs will be tied to each survey question
that will provide guidance as to what activities may qualify for credit,
especially if certain developments in patient safety have been
substantiated in the literature after publication of the NQF report.
Performance Improvement programs and project actions were given
high emphasis, as such, these programs will require thorough
literature reviews and examination of readily available practices be
undertaken. Such initiatives would include but not limited to the NQF
practices especially if there were new high impact actions that target
the problems listed in the NQF report. Far more important than
attestations of compliance to procedures, policies, and protocols are
ongoing programs that have regular measurement and process
improvement elements.
5. Sensitivity to use of the word “Problem”: Risk managers at hospital
organizations have expressed concern over the use of the word “problem”,
therefore wherever possible the term “performance opportunity” was used in
the survey in place of the word “problem”. That is not to say the word
problem is not used appropriately in the NQF report. It is.
The 4A framework recognizes the sequential and
interdependent nature of awareness of our performance
opportunities, accountability of leadership, the ability to
employ practices, and measurable action towards closing
performance gaps. This “4A Framework” (updated from a 3
A framework published by C. Denham in 2001) was used as
an organizational structure to allow systematic
customization of survey questions.
21
AWARENESS
4 A Framework
ACCOUNTABILITY
OUR GAP
In Strategic
or Ops Plan
Commit to
Strategic/Ops Plan
Measured Events
Report to Admin
Commitment
To Measure
and Report
THE GAP
Evidence
Of Education
Commitment
to Educate
• The 4 A Framework provides a graduated scale of
options for to Awareness, Accountability, Ability,
and Action.
• The survey design was intended to deliver partial
credit for partial progress in each of the 4 A
categories.
• Partial credit for commitment is provided not only to
help stratify the respondents but to create a
Hawthorne effect: to encourage commitment
through participation in the survey and recognition
that a hospital organization could increase its score
by making a commitment at the time of survey
response.
BOARD
Commitment to
Report Board
CEO
Commitment to
CEO Accountability
SR. EXECs
Commitment to
Exec
Accountability
DEPT HEAD
Commitment to
Dept. Head
Accountability
• The Rural Hospital Task Force will apply the 4 A
Framework to the first 3 Leapfrog Leaps. The
objective is to create a fair and reasonable set of
survey questions to address the unique
characteristics of rural hospitals.
ACTION
ABILITY
Enterprise PI
Rigorous Practice
Line Item
Budget
Commit to
Budget
Clinical Unit
Dept. or Svc Line PI
Dedicated HR
Commit to Clinical Unit,
Dept. or Svc. Line PI
Commit to
Dedicated HR
Invest in
Skills
Intermediate Level
Practice Actions
Commit to
Invest in Skills
Invest in
Education
Commit to
Invest in
Skills
Basic Practice
Actions
Commit to
Invest in
Education
Commit to PI
Confidential – Not to be distributed
© 2005 TMIT
Commit to Enterprise
PI or Rigorous
Practices
22
AWARENESS
ACCOUNTABILITY
AWARENESS
OUR GAP
OUR GAP
In Strategic
or Ops Plan
BOARD
In Strategic
Commit to
or Ops Plan
Strategic/Ops Plan
Measured Events
Report to Admin
Measured Events
Commitment
To Measure
Report to Admin
and Report
Commitment to
Report Board
Commit to
Strategic/Ops Plan
CEO
Commitment to
CEO Accountability
SR. EXECs
Commitment to
Exec
Accountability
THE GAP
Evidence
Of Education
THE GAP
Commitment
to Educate
Commitment
To Measure
and Report
DEPT HEAD
Commitment to
Dept. Head
Accountability
Evidence
Of Education
Commitment
to Educate
ABILITY
ACTION
Enterprise PI
Rigorous Practice
Line Item
Budget
Commit to
Budget
Clinical Unit
Dept. or Svc Line PI
Dedicated HR
Commit to Clinical Unit,
Dept. or Svc. Line PI
Commit to
Dedicated HR
Invest in
Skills
Intermediate Level
Practice Actions
Commit to
Invest in Skills
Invest in
Education
Commit to
Invest in
Skills
Basic Practice
Actions
Commit to
Invest in
Education
Commit to PI
Confidential – Not to be distributed
© 2005 TMIT
Commit to Enterprise
PI or Rigorous
Practices
23
ACCOUNTABILITY
ACCOUNTABILITY
AWARENESS
OUR GAP
In Strategic
or Ops Plan
BOARD
Commitment to
Report Board
BOARD
Commit to
Strategic/Ops Plan
CEO
Commitment
to
Commitment to
Report Board
Measured Events
Report to Admin
Commitment
To Measure
and Report
THE GAP
CEO
CEO Accountability
SR. EXECs
Commitment to
Commitment
to
Exec
Accountability
CEO Accountability
Evidence
Of Education
SR. EXECs
Commitment
to Educate
DEPT HEAD
DEPT HEAD
Commitment to
Dept.
Commitment
toHead
Accountability
Exec
Accountability
Commitment
to
ACTION
Dept. Head
Accountability
ABILITY
Enterprise PI
Rigorous Practice
Line Item
Budget
Commit to
Budget
Clinical Unit
Dept. or Svc Line PI
Dedicated HR
Commit to Clinical Unit,
Dept. or Svc. Line PI
Commit to
Dedicated HR
Invest in
Skills
Intermediate Level
Practice Actions
Commit to
Invest in Skills
Invest in
Education
Commit to
Invest in
Skills
Basic Practice
Actions
Commit to
Invest in
Education
Commit to PI
Confidential – Not to be distributed
© 2005 TMIT
Commit to Enterprise
PI or Rigorous
Practices
24
ACCOUNTABILITY
AWARENESS
OUR GAP
In Strategic
or Ops Plan
BOARD
Commitment to
Report Board
Commit to
Strategic/Ops Plan
Measured Events
Report to Admin
CEO
Commitment to
CEO Accountability
Commitment
To Measure
and Report
THE GAP
Evidence
Of Education
SR. EXECs
Commitment to
Exec
Accountability
ABILITY
DEPT HEAD
Commitment to
Dept. Head
Accountability
Commitment
to Educate
Line Item
Budget
ABILITY
ACTION
Commit to
Budget
Dedicated HR
Line Item
Budget
Commit to
Budget
Invest in
Skills Commit to
Enterprise PI
Rigorous Practice
Commit to
Dedicated HR
Clinical Unit
Dept. or Svc Line PI
Dedicated HR
Dedicated HR
Invest in
Skills
Commit to Clinical Unit,
Dept. or Svc. Line PI
Commit to
Invest in Skills
Intermediate Level
Practice Actions
Invest in Commit to
Education Invest in Skills Commit to
Invest in
Invest in
Education
Commit to
Invest in
Education
Commit to
Invest in
Skills
Basic Practice
Actions
Commit to PI
Education
Confidential – Not to be distributed
© 2005 TMIT
Commit to Enterprise
PI or Rigorous
Practices
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ACCOUNTABILITY
AWARENESS
OUR GAP
In Strategic
or Ops Plan
BOARD
Commitment to
Report Board
Commit to
Strategic/Ops Plan
Measured Events
Report to Admin
CEO
Commitment to
CEO Accountability
Commitment
To Measure
and Report
THE GAP
SR. EXECs
Evidence
Of Education
DEPT HEAD
ACTION
Commitment
to Educate
Enterprise PI
Rigorous Practice
ABILITY
Clinical Unit
Dept. or Svc Line PI
Line Item
Budget
Commit to
Budget
Dedicated HR
Commit to
Dedicated HR
Intermediate Level
Practice Actions
Invest in
Skills
Basic Practice
Actions
Commit to
Invest in Skills
Invest in
Education
Commitment to
Dept. Head
Accountability
ACTION
Commit
to Enterprise
PI or Rigorous
Practices
Enterprise PI
Rigorous Practice
Commit to Enterprise
Commit to Clinical
Unit,
PI or Rigorous
Dept. or Svc.Practices
Line PI
Clinical Unit
Dept. or Svc Line PI
Commit to
Invest
in
Intermediate
Level
Practice Actions
Skills
Commit to Clinical Unit,
Dept. or Svc. Line PI
Commit to
Invest in
Skills
Basic Practice
Actions
Commit to PI
Commit to
Invest in
Education
Commit to PI
Confidential – Not to be distributed
© 2005 TMIT
Commitment to
Exec
Accountability
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Leapfrog NQF Safe Practices Program
• Leapfrog NQF Leap
• NQF Survey Early Results
• Submitter’s Toolbox
• Research Test Bed
© 2005 TMIT
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www.leapfroggroup.org
Click Here
© 2004 TMIT
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TMIT
Click Here
© 2004 TMIT
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TMIT
© 2004 TMIT
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TMIT
© 2004 TMIT
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TMIT
NQF Survey Preliminary Results
• Overall number of survey respondents: 1,019
• Number of NQF Survey Respondents: 893
• NQF Survey Respondent Percentage: 88%
• 75% Non Profit – 25% For Profit
• Report to be Published 2nd Quarter of 2005
© 2005 TMIT
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NQF Survey Preliminary Results
• 7 in 10 hospitals require a pharmacist to review
all medication orders before medication is
given to patients
• 8 in 10 hospitals have implemented procedures
to avoid wrong-site surgeries
• 7 in 10 report they do not have an explicit
protocol to ensure adequate nursing staff
• 7 in 10 do not have policy to check with
patients to make sure they understand the risks
of their procedures
© 2005 TMIT
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NQF Survey Preliminary Results
• 6 in 10 lack procedures for preventing
malnutrition in patients
• 5 in 10 report they do not have procedures in
place to prevent bed sores (pressure ulcers)
• 4 in 10 hospitals lack policies requiring
workers to wash their hands with disinfectant
before and after seeing a patient
© 2005 TMIT
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Leapfrog NQF Safe Practices Program
• Leapfrog NQF Leap
• NQF Survey Early Results
• Submitter’s Toolbox
• Research Test Bed
© 2005 TMIT
35
Submitter’s Toolbox
• Submitter’s Toolbox: Five Stages
Prepare
© 2005 TMIT
Plan
Collect
36
Assess
Submit
www.leapfroggroup.org
Click Here
© 2005 TMIT
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Click Here
© 2005 TMIT
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Click Here to Obtain
Submitter’s Checklist
© 2005 TMIT
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Prepare
Plan
Collect
Assess
Submit
Stage 1: Prepare
• Obtain hard copy or digital PDF version of the NQF
Safe Practices for Better Health Care: A Consensus
Report
• Print a hard copy of the Leapfrog survey and
Frequently Asked Questions (FAQs)
• Organize Survey Submission team
© 2005 TMIT
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Click Here for NQF
Report Order Form
© 2005 TMIT
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© 2005 TMIT
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www.safetyleaders.org/nqfsp
Click Here to Buy PDF
© 2005 TMIT
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Click Here for Survey
© 2005 TMIT
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© 2005 TMIT
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Prepare
Plan
Collect
Assess
Submit
Stage 2: Plan
• Pull a team of “internal experts” together to help
answer the survey Including:
1.
2.
3.
4.
5.
Nursing
Pharmacy
Infection Control
Surgical Services
Administration
• Assign team member responsibilities for individual
survey questions
• Develop Survey Submission Plan
© 2005 TMIT
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Prepare
Plan
Collect
Assess
Submit
Stage 3: Collect
• Each team member collects source documents to
support survey question answers
• Inventory source documents to each Safe Practice;
establish a filing system as resource for gap
analysis and future survey submissions
• Perform gap analysis to determine what
documents are missing that need to support
remaining survey questions
© 2005 TMIT
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Prepare
Plan
Collect
Assess
Submit
Stage 4: Assess
• Create a draft survey to determine baseline score
• Identify pre-submission actions that can be
immediately implemented to finalize an answer to
any survey questions.
• Identify Commitment answers to survey
questions to optimize survey score
• Prepare potential Commitment Scenarios
(see example)
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Prepare
Plan
Collect
Assess
Stage 5: Submit
Final CEO Briefing
• Review baseline survey score
• Make decisions regarding immediate
pre-submission actions
• Present optimized score with commitments
• Give recommendations for Performance
Improvement Projects
© 2005 TMIT
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Submit
Prepare
Plan
Collect
Assess
Submit
Stage 5: Submit (Continued)
Submit to Leapfrog Web Site:
www.leapfrog.medstat.com
• Obtain CEO agreement to certify submission
• Acquire a Security Code from the Leapfrog Web
Site
Create Follow-up Action Plan
© 2005 TMIT
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“The Hawthorne Effect”
•
Definition: Initial improvement in a process of
production caused by the obtrusive
observation of that process(1)
or in simple English…
Individual behaviors may be altered because
they know they are being studied
(1) Source: Web Dictionary of Cybernetics and Systems
© 2005 TMIT
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“The Hawthorne Effect”
•
We Recommended Submitters Generate 3
Scenarios:
1. Raw Score (with no commitments or immediate
actions)
2. Score if Immediate Actions Taken (pre-submission)
3. Score if Commitments Made ( up-score by
commitments)
•
We recommended Submitter calculate costs to up
score by scenario
•
Our Objective: To have the CEO allocate
resources and “go for it”
© 2005 TMIT
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Leapfrog NQF Safe Practices Program
• Leapfrog NQF Leap
• NQF Survey Early Results
• Submitter’s Toolbox
• Research Test Bed
© 2005 TMIT
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© 2005 TMIT
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© 2005 TMIT
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Click Here
© 2005 TMIT
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© 2005 TMIT
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NQFSP Research Test Bed
• All Invited
• Early Access to Upcoming Versions
• No Cost
More Information at:
www.SafetyLeaders.org
Contact: [email protected]
Phone: (757) 565-5411
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