Re-engineering of Process and Culture Required to Rise to New Levels of Transparency, Patient Safety


Protecting patients from surgical and healthcare-associated infections (HAIs) is always part of the safety agenda at the National Patient Safety Foundation, says the organizations president Diane Pinakiewicz. The organization has partnered with and supported the Association for Professionals in Infection Control and Epidemiology (APIC), and last year developed tools to help consumers understand the patients role in protecting against HAIs.

By Karin Lillis

Protecting patients from surgical and healthcare-associated infections (HAIs) is always part of the safety agenda at the National Patient Safety Foundation, says the organizations president Diane Pinakiewicz. The organization has partnered with and supported the Association for Professionals in Infection Control and Epidemiology (APIC), and last year developed tools to help consumers understand the patients role in protecting against HAIs.

Hospital-acquired infections most commonly catheter-related bloodstream infections, hospital-acquired pneumonia and surgical site infections -- are among the foundations hot-button issues. Nearly 9 percent of patients hospitalized worldwide have an HAI at any given time, according to the World Health Organization.

In the United States, 5 percent of patients get an HAI and 100,000 die every year, according to the NPSF. Usually HAIs present within 48 hours of the patients admission, but infections that occur after a patient is discharged are also considered HAIs if the pathogen was acquired during treatment, the NPSF notes.

Most recently the NPSF announced its support of the federal governments Partnership for Patients Initiative. Launched in 2011, the program focuses on improving healthcare and reducing costs in part by reducing causes of harm in healthcare.

The Partnership for Patients initiative will mark its one-year anniversary at the NPSF 14th Congress, scheduled for May 23-25, 2012 in Washington, D.C.; the Partnership will be an integral part of each future congress.

According to the Partnership for Patients initiative, the program has two main goals to help patients from getting injured or sicker and to help them heal without complication. The program estimates that the number of preventable, hospital-acquired infections could decrease by 40 percent next year, compared to 2010. That means 1.8 million fewer injuries and more than 60,000 lives saved, according to the partnership. In 2013, healthcare organizations participating in the partnership could see a 20 percent reduction in hospital readmissions -- adding up to more than 1.6 million patients who will recover from illness without suffering a preventable complication requiring re-hospitalization within 30 days of discharge.

It is such a wonderful thing to have the federal government launch a program and make a very public statement about the importance of patient safety, Pinakiewicz says. This is the first time weve seen such a strong endorsement for work to be done on a federal level and for funding to assist the provider community."

The Partnership is a public-private initiative that includes hospitals and organizations representing physicians and nurses; consumer and patient organization; employers, unions, health plans and states; and Medicare.

There are a lot of positives associated with the [federal program] to provide some organized assistance to the provider community and collect everyone around a specific point of focus so practices can be more universally adopted, Pinakiewicz says.
But how do hospitals make changes necessary to reduce risks and complications?

Hospitals have to comply with all sorts of regulations and requirements, while resources are shrinking, the workforce is exhausted and disconnected from work and distracted by nonpatient care requirements, Pinakiewicz says.

Were facing changes in reimbursement (paying for value and not volume) and coordinating care [across the healthcare continuum]. Youre improving while youre running. Its going to take a major re-engineering of process and culture, she continued. We need transparency and team engagement. If we dont get those things down, changes are harder to implement and harder to sustain.

Getting It Right
So many organizations are doing fabulous things. The challenge is, once someone figures out how to do it, getting everyone who does it that way. Pinakiewicz says.

Michigan is a leader in the field. In February 2009, the Michigan Health and Hospital Association launched its Surveillance for Healthcare Associated and Resistant Pathogens (SHARP) Unit Healthcare Associated Infection program. SHARP, a voluntary reporting program, is a collaboration among the state hospital association, health department and quality improvement organization. Last September, the Department of Health and Human Services invited representatives from Michigans SHARP program to participate in a national focus group.
The [Michigan] hospital association continues to lead the majority of state prevention initiatives, says a report from the focus group.

In 2003, 100 ICUs in Michigan were the first to participate the Comprehensive Unit-based Safety Program (CUSP) initiative. According to the federal Agency for Healthcare Research and Quality (AHRQ), the project targeted clinicians' use of five evidence-based procedures, recommended by the Centers for Disease Control and Prevention (CDC), to reduce rates of central-line associated bloodstream infections hand hygiene, using full-barrier precautions during the insertion of central venous catheters, cleaning the skin with chlorhexidine, avoiding the femoral site when possible and removing unnecessary catheters.

The initiative, known as the Comprehensive Unit-based Safety Program (CUSP), was implemented through the Keystone Project in Michigan hospitals.

Last year AHRQ reported that ICUs at large and small hospitals stopped central-line associated bloodstream infections for up to two years, according to a study published in the Archives of Internal Medicine The researchers found that 60 percent of the 80 ICUs evaluated went one year or more without an infection, and 26 percent achieved two years or more. Smaller hospitals sustained zero infections longer than larger hospitals, the researchers found.

"This study demonstrates that any hospital ICU can go a year or two without an infection if it commits to implementing this targeted quality improvement initiative. With CUSP, the goal of a year or two without a CLABSI is achievable,"  the study's lead author, Peter J. Pronovost, MD, PhD, a professor of anesthesiology and critical care medicine at The Johns Hopkins University School of Medicine in Baltimore, said in a news release. In conjunction with the Michigan Health and Hospital Association, Pronovost led development of the AHRQ-sponsored Keystone Intensive Care Unit Project to reduce infections in Michigan hospitals by implementing CUSP.

Getting Certified
Infection preventionists and other healthcare providers can earn professional patient safety certification through an organization established by the NPSF the Certification Board for Professionals in Patient Safety (CBPPS). (See "Professional in Patient Safety Certification" below.)

We cant expect people to comply with or support patient safety strategies unless they understand them, Pinakiewicz says.
Essentially, the program sets evidence-based competency standards for healthcare professionals, offers a way for them to demonstrate their skill and proficiency and helps employers validate a candidates safety knowledge, according to the CBPPS.

Professionals who meet certain educational and professional criteria are tested on six core patient safety domains: culture, leadership, risk identification and analysis, data management system design, mitigating risk through systems thinking, design and human factors analysis, and external influences on patient safety.

Its unthinkable that today and in the future of healthcare there would be people inside the system who dont know how to do a root-cause analysis or that the team dynamic is critical to patient care, Pinakiewicz says.

NPSF also offers an online patient safety curriculum, a 10-module course that includes best practices and ways to overcome barriers to safe care. That includes a section on healthcare-associated infections.

Getting Educated
Todays healthcare consumers are more educated and expect to participate actively in their care, Pinakiewicz says. People are talking on social media sites and exchanging information on healthcare and providers -- including patient-to-patient advice, Pinakiewicz says. Patients are more engaged in their care, and its becoming necessary for the healthcare system to be responsive. Social media, networking and information sharing and consumer activism are forcing healthcare organizations to be a lot more responsive a lot more quickly. If we can engage patients it will help protect them against [harm], but were still not good at optimizing that potential.

The National Patient Safety Foundation has an arsenal of tools to help patients communicate more effectively with their providers. The Ask Me 3 initiative encourages patients to understand the answers to three questions  -- what is my main problem, what do I need to do and why is it important for me to do this? The education program promotes communication among healthcare providers and patients, leading to improved treatment outcomes, the NPSF says.

Because many patients admitted to the hospital could potentially be at risk of infection, patients in the hospital can adapt the Ask Me 3 idea to specifically ask questions related to infection risk and prevention. For example, patients might ask,
-What causes the spread of infection?
-What can I do to protect myself and how will you (the healthcare provider) protect me?
-Why is this important?
The NPSFs Stand Up for Patient Safety program offers member organizations tools to launch, sustain and advance patient safety initiatives, according to the foundation. Begun in 2002 with 16 founding members, the Stand Up program now has a membership of over 400 healthcare facilities, the NPSF says.

According to, hospitals participating in the Stand Up program learn to:
- Engage front-line staff and leadership in continuing education opportunities, including the NPSF Professional Learning Series and NPSF Patient Safety Congress
- Spread health literacy and communication tools throughout your patient population using the Ask Me 3 program at NPSF and tools provided in the Patient Safety Awareness Week Toolkit
- Expand current policies and procedures to include best practices from the field and integrate new approaches to topics such as disclosure and apology

Since 2002, the foundation also sponsors Patient Safety Awareness Week, held this year in March. This years theme Be Aware for Safe Care emphasized that safety issues affect both patients and providers.
The more we work to promote patient safety, the more we all benefit from a safe healthcare system, Pinakiewicz notes.

NSPF encourages creative collaboration among provider groups, patient advocates and other community organizations to help patients and consumers understand how they can participate to be part of the solution, Pinakiewicz says. The more we work to promote patient safety, the more we all benefit from a safe healthcare system.

Karin Lillis is a freelance writer.

Professional in Patient Safety Certification

The Certification Board for Professionals in Patient Safety (CBPPS) launched the Certified Professional in Patient Safety (CPPS) exam during National Patient Safety Week last month.

The credentialing profess helps establish core patient safety standards and benchmarks and sets an expected proficiency level. Those working in patient safety have a way to demonstrate The Certified Professional in Patient Safety (CPPS) credential is maintained on a three-year cycle of re-examination.
Candidates for the CPPS credential are those who include patient safety practices as an integral component of current or future professional responsibilities. That includes patient safety professionals, clinicians, nonclinical healthcare workers, and other healthcare professionals.

 Candidates must possess academic and professional experience at one of the following levels:
Baccalaureate degree or higher plus three years of experience (includes time spent in clinical rotations and residency programs) in a healthcare setting  or with a provider of services to the healthcare industry
Associate degree or equivalent plus five years of experience (includes time spent in clinical rotations) in a healthcare setting or with a provider of services to the healthcare industry


National Patient Safety Foundation

Partnership for Patients

Certification Board for Professionals in Patient Safety



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