OPERATIONAL EXCELLENCE & CMS PSSM

SafeQual’s operational excellence model includes client best practices our software supports, positioning our clients to resolutely pursue CMS PSSM vision of patient safety excellence.

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Event Reporting

Staff/Board Engagement

Educate all staff in the organization as to why incident reporting is important. Highlight how their insights and observations are invaluable for identifying safety risks and improving processes.

Regularly communicate how incidents drive change and enhance safety. Share how the learnings from reported incidents improved safety.

Set up close-loop reporter feedback mechanisms to keep staff engaged in continuous reporting. (PSSM D4-A)

Standardize incident reporting processes across the organization, in-patient and ambulatory settings, to ensure consistency and facilitate data collection.

Establish processes for board members to be alerted of confirmed serious events within 3 business days and provide detailed metrics for discussion at board meetings. (PSSM D1-E)

Allocate at least 20% of regular senior governing board meeting discussions around patient and workforce initiatives. (PSSM D1-D)

Culture/Training

Leadership should be active in supporting a safety culture by championing incident reporting, allocating resources, encouraging transparency and accountability, and participating in safety activities, e.g. monthly unit rounding. (PSSM D3-D)

Foster a safety culture by training staff to act in non-punitive manner, e.g. by avoiding giving negative or critical feedback. Electronic systems with the Just Culture algorithm embedded in the workflow can help advance a just and learning culture.(PSSM D2-C) (PSSM D3-D)

Regularly assess patient safety competencies of all staff, including C-suite executives and board members, by implementing a patient safety training and education program. (PSSM D2-D) (PSSM D3-D)

There are free resources from Patient Safety Network (PSNet). Also, leverage healthcare learning management systems (LMS) that can integrate seamlessly into your staff’s hectic daily routines and that can help track compliance.

Great Catch

Encourage reporting of Near Miss and Good Catch events so that lessons can be learned, appropriate controls can be implemented, and information can be shared to prevent recurrence.

Set up a Great Catch program that recognize the individuals and departments involved publicly. E.g. recount the events in monthly newsletter, give small prizes (movie tickets, coffee gift cards, etc.), include the events in yearly reviews

Technology

Analytics

Use robust analytics to identify trends, patterns, and prioritize areas for improvement.

Reports and dashboards should be in real-time and have drill-down and filtering capabilities to enable timely identification and resolution of issues.

Make public the patient safety metrics in hospital units for staff, patients, families and visitors to see. (PSSM D4-C)

Actionable/Augmented Data

The technology should be used to collect not just data, but actionable data, so that areas for improvement can be prioritized. (PSSM D3-D)

Use emerging technology, such as Artificial Intelligence, that can augment data to promote critical thinking, be used as a second set of eyes, and reduce anchoring bias

Access/Ease of Use

The technology should be easy for users to access such as integration with single sign-on systems to eliminate the need for manual logins, and the software should be compatible with mobile devices.

To reduce data entry time and errors, forms should have skip logic and automatically populating staff and patient demographics information.

One System of Record

The technology should allow for cross-functional collaboration between departments so that all related data can be located on-demand easily.

The technology should allow patient safety, quality and risk management teams to work in one system of record.

The system should be a “Safety Work Product” -a confidential safety reporting system -that encourages the reporting and analysis of medical errors and patient safety events. (PSSM D4-A)

Process/Quality Improvements

CPR/Equity

Set up a communication and resolution (CPR) program to ensure there is transparency, accountability and honesty when dealing with adverse events. Example: using the AHRQ CANDOR toolkit. (PSSM D4-D)

Use measures -timeliness to response, patient & family engagement, staff engagement & support, corrective action & improvement, legal & financial outcomes, adverse event reporting and learning, cultural metrics, educational & training measures, outcomes for the patient, external benchmarks and accreditation -to gauge the effectiveness of the CPR program. (PSSM D4-D) (PSSM D4-E)

To ensure there is accountability, there must be at least one owner for each high-priority measures (KPIs -key performance indicators).

Apply an equity lens to quality and safety initiatives by embedding equity questions to all risk management event discussions. An equity question example is “Discuss any biases or structural inequity that contributed to this event”. (PSSM D2-B)

Triage Workflow/Backlogged Events

Include a triage workflow in the incident management process to allow for red events to be managed timely and with the appropriate leadership involvement.

Setup a standardized Rapid Event Investigation (REI) process for the evaluation of high-frequency, low-intensity incidents to capture apparent cause/s to enable learning from all events reported.

Quality Methodologies / Tools

Use the National Action Plan tool (IHI) to develop an action plan for patient and workforce safety improvement.

Adopt High Reliability Organization (HRO) principles across all care settings. (PSSM D2-A)

Use the Plan-Do-Study-Act (PDSA) tool to standardize the documentation of performance improvement projects. Engage the board and c-suite leadership in, at least, system-wide patient safety initiatives. (PSSM D1-B) (PSSM D3-D)

Establish a standardized process for conducting Root Cause Analyses and Actions (RCA2) on medical errors and adverse events. (PSSM D3-B). Similarly, set up a standardized process to perform Success Cause Analysis (SCA) on Great Catches to identify the elements that led to positive outcomes. Create action plans for system improvement for the processes. Ensure a mechanism is in place to track the corrective actions to ensure they are followed through to completion.

Join a Patient Safety Organization (PSO) to share insights, best practices. learn from each other’s experiences and implement successful strategies forreducing patient harm. (PSSM D3-E) (PSSM D4-B)

Metrics

KPIs

Know your Patient Safety Event metrics:

  • Number of events reported
  • Number/percentage of events reported within 48 hours
  • Number/percentage of events reviewed within 14 days
  • Number/percentage of events closed within 30 days
  • Average number of apparent causes per event
  • Number of events per 1000 patient days (Acute)
  • Number of events per 100,000 patient days (Ambulatory)

Know your Complaint/Grievance metrics:

  • Count/percentage reviewed within 7 days
  • Count/percentage closed within 30 days
  • Compliance for grievance acknowledgement letter sent within 7 days
  • Compliance for grievance resolution letter sent within 30 days


Use the metrics for leadership performance reviews and compensation (PSSM D1-A)

Red Events

Implement a Red Event Dashboard that monitors government mandated reporting, high severity events defined by your organization, and any unusual spikes in specific event types to prevent oversight.

Safety Culture

Annually, conduct patient safety surveys to know if your risk reduction projects are advancing patient safety and to gain insight into what areas need improvements. (PSSM D3-C)

Setup Patient Safety Event Dashboard to monitor and inform on performance on patient safety activities.

Setup a Just Culture Dashboard to learn the causes and corrective actions taken from a safety culture perspective. (PSSM D3-C)

Regulatory Compliance/Claims

Setup a Rounding Dashboard to know the status of the findings from your safety, quality, nursing and patient experience rounds. (PSSM D3-D)

Setup an Accreditation Dashboard to track the resolution of the findings from external accreditation bodies (e.g. TJC, DNV, Fire, DOH, etc.)

Setup a Claims Dashboard to track potential compensable events (PCE), claims, lawsuits and subpoenas. Properly managing PCEs has significant impact on the outcome of a malpractice case that may follow.

A group of four medical professionals standing together, wearing scrubs and lab coats. The background features large windows with vertical blinds. The team is happy because of the benefits of incident reporting that they had in the hospital.

Workforce

Staff Events

Empower staff to report physical safety issues such as lack of PPE, inadequate training on use of PPE, ventilation, sanitation, injury and workplace violence events.

Establish a consistent procedure for reviewing staff incidents that incorporates gathering data for learning to prevent recurrence. For example, categorize the reasons behind each event based on the situation, behavior, and type of error. (PSSM D2-E)

Incorporate equity into practices, such as RCA conducted after workplace injury, to promote racial justice and health equity.

Apply a Just Culture approach when deciding on corrective actions for staff to improve their psychological and emotional well-being. (PSSM D2-C)

Setup a standardize process to capture and share compliments given to staff from patients and their families and friends to encourage high-quality healthcare and heightened job satisfaction.

Occupational Health and Safety Metrics

Know your staffs’ compliance:

  • Vaccination (Flu, Covid-19, Varicella, MMR, Hep-A, etc.)
  • Tuberculosis Screening
  • Respirator Fit Testing
  • Medical Monitoring after exposures


Know your Staff Events metrics:

  • Number of injuries reported
  • Number of workplace violence events
  • Number/percentage of injuries by type
  • Number/percentage of OSHA reportable events (PSSM D2-E)

Productivity/Bright Ideas

Measure your staffs’ engagement with your safety, quality and risk management systems with activity points to identify opportunities for improvement or lack of resources to meet your organization’s safety and quality objectives.

Understand if the staffing level and mix contributed to each safety event.

Engage the governing board to work with leadership to ensure there are adequate resources to support patient safety. (PSSM D1-C)

Establish a procedure for staff to share safety and quality improvement ideas. Since they work on the front lines, their insights are invaluable. The process not only enhances patient and workplace safety but also boosts job satisfaction.

Patient/Family Engagement

EMR Patient Portal

Provide patients access to view their medical records and clinical notes. (PSSM D5-C)

Care Management

Encourage family members/patient designated persons to be part of the care team by including them in bedside rounding, shift reporting, discharge planning, etc. (PSSM D5-E)

PFAC

Set up a Patient and Family Advisory Council (PFAC) to better understand the perspective of patients and families and to bring views of patients and clinicians closer. (PSSM D5-A)

Include patients and caregivers who are diverse and representative of the patient population in the PFAC. (PSSM D5-B)

Feedback

Make it easy for patients and families to provide safety/service concerns and suggestions for improvement by promoting the various ways they can provide feedback to the organization. For example, patient can scan a QR code posted in the exam room and wall in access areas, electronic feedback form on the website, etc. (PSSM D5-D)

Gather patient feedback with patient satisfaction surveys. For example, after each encounter, deliver to patients a quick and micro survey that allows patients to leave comments for each question. (PSSM D5-D)

Standardize Feedback Management

Manage feedback from patients and their families the same way, regardless of the source system. For example, a negative feedback from a survey by text message or on paper survey should be managed the same way.

Positive feedback for staff should be managed as compliments that are shared in the organization and included in yearly reviews.