The Joint Commission:

For Joint Commission Compliance Strategies

The Source
March 2008 Volume 6 Issue 3

TM

CONTENTS
1. Reducing the Risk of Errors Associated with Concentrated Electrolyte Solutions Learn about methods to comply with Standard MM.7.10 and risk-reduction strategies for your medication management system.
ACCREDITATION ESSENTIALS:

Reducing the Risk of Errors Associated with Concentrated Electrolyte Solutions

High-Risk, High-Alert Drugs and Complying with Standard MM.7.10

4.

Medical Staff Communication: Cornerstone of Care Coordination Standard MS.2.20 Read about methods for complying with Standard MS.2.20 and the importance of structured communication techniques to convey the proper information at the correct time to the correct people. 6.
ACCREDITATION ESSENTIALS LINK:

Maintaining Existing Privileges Standard MS.4.40 Read about the importance of conducting objective and fact-based evaluations for your medical staff. 9.
SPOTLIGHT ON SUCCESS:

Seton Family of Hospitals Improves Perinatal Care: Complying with the Improving Organization Performance Standards PI.3.10 and PI.3.20 in 2008 2007 Ernest A. Codman Award winner Seton Family of Hospitals illustrate methods and processes used to improve perinatal care at their organization.

ndiluted potassium chloride (KCL) is used to execute death row prisoners.1 In the United States, 5 to 10 patients die every year when they are accidentally injected with KCL.1 Although KCL is the most common electrolyte associated with medication errors, potassium phosphate concentrate and hypertonic (> 0.9%) saline can also be lethal if not administered appropriately.2 Reversing the effects of improperly administered concentrated electrolytes is frequently challenging, and death is the typical patient outcome.2 Fortunately, most catastrophic errors can be eliminated by adopting some simple precautionary measures.2 Standard MM.7.10* requires that organizations develop processes for High-alert drugs include investigational drugs, managing high-risk or high-alert medcontrolled medications, drugs not approved by ications. Elements of performance for the Food and Drug Administration, medications MM.7.10 include the following: with a narrow therapeutic range, psychothera1. The organization identifies the highpeutic medications, and look-alike/sound-alike risk or high-alert medications used medications. Organizations should make the within the organization, if any. determination as to whether new medications to 2. Based on the services provided, the the organization are high risk. organization develops processes for procuring, storing, ordering, transcribing, preparing, dispensing, administering, and/or monitoring high-risk or high-alert medications (see Sidebar 1, page 3, for a detailed description of these processes). 3. The processes for managing high-risk or high-alert medications are implemented.
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* Standard MM.7.10 applies to the following programs: ambulatory care, behavioral health care, critical access hospitals, home care, hospitals, and long term care.

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Reducing the Risk of Errors Associated with Concentrated Electrolyte Solutions Continued from page 1

Selection and Procurement

High-risk or high-alert drugs, such as concentrated electrolyte solutions, are those medications that have the highest risk of causing injury when misused, or that carry a higher risk for abuse, errors, or other adverse outcomes. Lists of high-risk or high-alert drugs are available from such organizations as the Institute for Safe Medication Practices, and the United States Pharmacopeia, based on national data about medication use. However, organizations need to develop their own list of high-risk or high-alert drugs based on their unique utilization patterns or drugs, and their own internal data about medication errors and sentinel events. Examples of high-alert drugs include investigational drugs, controlled medications, medications not on the approved Food and Drug Administration list, medications with a narrow therapeutic range, psychotherapeutic medications, and look-alike/ sound-alike medications. Organizations determine whether medications that are new to the market or new to the organization are high risk.
Risk-Reduction Strategies

Risk Factors1,5: Improperly adding KCL to intravenous (IV) solutions Mistaking KCL for other medications such as saline, heparin, or furosemide Strategies for Risk Reduction3,5,6: Use premixed solutions or commercially outsourced admixtures, when possible. Standardize and limit the range of KCL dilutions available. Purchase concentrated electrolyte solutions from different vendors, if possible, to avoid packaging similarities. Inventory all concentrated electrolytes in the organization and perform a failure mode and effects analysis. Evaluate the look-alike potential of product containers.
Storage

ed from other drugs, and distinctly separate by product type. Do not allow nurses to enter the pharmacy when it is closed. Keep a stock of carefully selected after-hours medications, including premixed small- and large-volume KCL in a secured area, such as a controlledaccess cabinet.
Ordering and Transcribing

The risk for error can occur during any of the components of the medication management system. Potential risks and strategies to mitigate these risks are discussed in detail on the following pages.
The Joint Commission: The SourceTM Senior Editor: Ilese J. Chatman Project Manager: Andrew Bernotas Manager, Publications: Paul Reis Associate Director, Editorial Development: Diane Bell Executive Director, Publications: Catherine Chopp Hinckley, Ph.D. Vice President, Learning: Charles Macfarlane, F.A.C.H.E. Accreditation Preparation Champion: John Wallin Contributing Writers: Ruth Carol, Julie Henry, Kathleen Vega

Risk Factors5: Storing KCL on patient care units Storing concentrated electrolytes in close proximity to other drugs with similar packaging in the pharmacy Not having a pharmacy that operates 24/7 Strategies for Risk Reduction2,3,5,6: Ideally, remove concentrated electrolyte solutions from all nursing units; store in specialized pharmacy preparation areas. Label with a visible florescent warning label that states MUST BE DILUTED. In the pharmacy, store bulk supplies and immediate inventory of concentrated electrolytes in an area segregat-

Risk Factors5: Availability of multiple concentrations of the same drug Illegible handwriting Incomplete orders Use of the term bolus, which is mistaken to mean that the dose should be given by IV push, using a syringe Strategies for Risk Reduction2,5,6: Prescribe potassium solutions for intravenous administration in those concentrations that are available as commercially prepared ready-to-use diluted solutions. Include the rate of infusion in all orders. Use preprinted order forms. Standardize terminology for prescribing; the term bolus should not be used in reference to KCL. Program alerts into computer systems to warn of excessive doses or of the need for dose adjustment as indicated by laboratory results.
Preparation and Dispensing

Risk Factors5: Solutions being prepared by untrained staff Human error Vials being dispensed to hospital units

Subscription Information: The Joint Commission: The SourceTM (ISSN:1542-8672) is published monthly by Joint Commission Resources, One Renaissance Boulevard, Oakbrook Terrace, IL 60181; 630/792-5000. Send address corrections to: The Joint Commission: The SourceTM, Superior Fulfillment, 131 West First Street, Duluth, MN 55802-2065 Annual subscription rates for 2008: United States$299 for both print and online, $249 for online only; Mexico/Canada$350 for both print and online, $249 for online only; all other countries$389 for both print and online, $249 for online only; online site licenseContact Superior Fulfillment, 800/746-6578, for pricing. Back issues are $25 each (postage paid). Direct all other inquiries to Superior Fulfillment, 800/7466578. Editorial Policy: Reference to a name, an organization, a product, or a service in The Joint Commission: The Source TM should not be construed as an endorsement by Joint Commission Resources, nor is failure to include a name, an organization, a product, or a service to be construed as disapproval. 2008 by the Joint Commission on Accreditation of Healthcare Organizations. No part of this publication may be reproduced or transmitted in any form or by any means without written permission.

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Sidebar 1. Components of the Medication Management System

Universal processes essential to the medication management system include the following: Preparation: The compounding, manipulation, or other Selection: Safe and appropriate selection of medicaactivity needed to get a medication ready for administrations available for use in the organization tion as ordered Procurement: The task of obtaining selected medica Dispensing: Providing, furnishing, or otherwise making tions that are not available from the organizations own available a supply of medication to the patient for whom pharmacy from a source outside the organization it is ordered according to a prescription or medication Storage: Maintaining a supply of medications on the order. Dispensing does not include providing an individorganizations premises. Storage includes medications ual with a dose of medication previously dispensed by a stored in the pharmacy, as well as all other locations on pharmacy. the premises, and addresses safety, stability, availability, Administration: The provision of a prescribed and preand security of medications. pared dose of an identified medication to the individual Ordering/Prescribing: Synonymous terms for when an for whom it was ordered. This includes directly introducauthorized person transmits a legal order or prescription ing the medication into or onto the individuals body or that directs the preparing, dispensing, and/or administerproviding the medication to the individual, who introing of a specific medication to a specific patient. duces the medication into or onto his or her own body. Ordering and prescribing do not include requisitions to Monitoring: The evaluation of a patient throughout the order stock supplies. continuum of care, to ascertain the effectiveness and Transcribing: A process in which a person other than efficacy of the medication and to prevent the occurrence the prescriber may rewrite or retype the order of any serious adverse outcomes. The perceptions of the Distribution: Providing, furnishing, or otherwise making patient should be considered during monitoring. available a supply of medications to the health care provider

Strategies for Risk Reduction2,3,5,6: If there is a need for a potassium solution in a dilution that is not commercially prepared in ready-touse diluted form, prepare the solution in the pharmacy. Label the prepared solution with a HIGH-RISK WARNING label prior to administration. Require a pharmacist to perform a final, independent check of all products used for IV admixtures of electrolyte solutions. Vials should not be dispensed for individual patients. The pharmacy should dispense premixed solutions or prepare patient-specific admixtures as needed. Although some hospitals may make an exception for the cardiac bypass surgical suite, many hospitals have been able to eliminate vials in all areas by providing pharmacy-prepared mini-bags of selected concentrations.

Administration

Risk Factors : Diluted KCL being infused too rapidly Undiluted KCL being administered intravenously Concentrated electrolyte solutions administered to the wrong patient Strategies for Risk Reduction2,6: Use an infusion pump to administer potassium riders. Require an independent double check for correct product, dosage, method of delivery, dilution, and patient prior to IV administration of concentrated electrolyte solutions.
5

py; perform electrocardiograph as indicated. Establish a standard protocol for frequency of laboratory studies and monitoring of electrolyte levels. The Source References
1. American Health Consultants: Medication errors: Keep close tabs on your KCL (potassium chloride). Hosp Peer Rev 23:101102, Jun. 1998. 2. Joint Commission International Center for Patient Safety: Control of Concentrated Electrolyte Solutions. WHO Collaborating Centre for Patient Safety Solutions. http://www.jcipatientsafety.org/24725/ (accessed Dec. 20, 2007). 3. Institute for Safe Medication Practices: Potassium May No Longer Be Stocked on Patient Care Units, but Serious Threats Still Exist! http://www.ismp.org/newsletters/ acutecare/articles/20071004.asp?ptr=y (accessed Dec. 30, 2007). 4. Joint Commission Resources: Understanding Medication Management in Your Health Care Organization. Joint Commission on Accreditation of Healthcare Organizations, Oakbrook Terrace, IL, 2006. 5. American Pharmacists Association (AphA): Medication Errors. Washington DC: APhA 2007. 6. National Patient Safety Agency: Patient safety alert on the prevention of accidental overdose with intravenous potassium, Jul. 2002.

Monitoring

Risk Factors: No adjustment in orders based on new laboratory results No policy for repeat laboratory studies and electrolyte monitoring Strategies for Risk Reduction5: Monitor patients electrolytes before, during, and after replacement thera-

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ACCREDITATION ESSENTIALS

Medical Staff Communication: Cornerstone of Care CoordinationStandard MS.2.20

he management and coordination of patient care, treatment, and services calls for practitioners with the appropriate privileges to collaborate. Effective communication is an underpinning of their coordination efforts that are essential to the safe management of patient care, treatment, and services. Health care organizations that use structured communication techniques to address the content, timing, and purpose of communication can assist practitioners in conveying the proper information at the correct time to the correct people. Many of these techniques can be used in clinical arenas throughout the organization or health care setting.
SBAR

Situational Awareness

Briefings

The SituationBackgroundAssessment Recommendation (SBAR) technique is useful for framing a brief and concise conversation, particularly one that is emergent in nature. SBAR sets expectations for what will be communicated among team members and how. This approach also promotes critical thinking because the clinician initiating the communication knows to provide the physician not only with an assessment of the patients situation, but a recommendation for how to handle it. SBAR stands for the following1: 1. SituationWhat is going on with the patient? 2. BackgroundWhat is the clinical background or context? 3. AssessmentWhat do I think the problem is? 4. RecommendationWhat would I do to correct it?

Situational awareness involves an ongoing dialogue between team members to maintain awareness of the current situation, typically a procedure or process that is under way. This strategy keeps all the practitioners in agreement with regard to recognizing potential problem areas and planning how to address them, should they occur. This technique also helps clinicians act in an effective manner by thinking ahead to discuss and plan contingencies. Red flags that signal a loss of situational awareness are as follows2: Ambiguity Reduced/poor communication Confusion Trying something new under pressure Deviating from established norms Verbal violence Doesnt feel right Fixation Boredom Task saturation Being rushed/behind schedule
Call Out

Using this technique, practitioners call out each phase of a process as they begin it, letting other team members know that it is okay to proceed. The phases are called aloud, particularly during rapidly-changing situations. In the operating room (OR), for example, this strategy is typically used at two points: the start of a procedure, and the closing. But it can also be used at other pivotal moments, such as acknowledging the correct sponge count, or in anticipation of the next step in the process, such as the patient is coming off bypass. When using this technique, clinicians should speak clearly and loudly.

These short discussions between team members get all the practitioners at the same starting point, thus promoting a sense of collaboration among the health care team and helping avoid surprises. During briefings, clinicians compare notes, identify what they want to accomplish, identify resources to do so, and anticipate obstacles. It could be done at the beginning of the shift or at any point in any clinical care situation, such as the beginning of a surgery. When conducting briefings, practitioners should include the following steps2: Get the persons attention. Make eye contact, face the person. Introduce yourself. Use the individuals name. Ask knowable information. Explicitly ask for input. Provide information. Talk about next steps. Encourage ongoing monitoring and cross-checking. Similarly, the Neonatal Intensive Care Quality Improvement Collaborative 2002a collaborative of five tertiary perinatal centers designed to improve collaboration, communication, and coordination between maternal and neonatal caregiversdeveloped the following steps to improve communication during delivery room crises3: Get the persons attention. Express your concern. State the problem. Recommend action. Achieve a decision. Make eye contact. Listen to understand. Repeat back what the person says. Call people by their first name.

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In the Institute for Healthcare Improvements version of briefings, known as huddles, the care team assembles at a predetermined time each day to examine the schedule and anticipate the needs of the patients coming in that day.4 Team members can discuss which patients on the schedule are unlikely to show up for their appointments, either because theyve been hospitalized, cancelled their appointments, or were in the previous week; what equipment will be necessary; and what additional services can be provided at the appointment to minimize a recurring visit. Lessons learned from huddles are recorded and reviewed at weekly team meetings. After implementing a briefings project in the OR at Orange County Kaiser, wrong-site surgeries, which has been a problem, became nonexistent.1 The OR was perceived as having an outstanding environment with regard to safety and teamwork. Nursing turnover was reduced by 16%, with 80% of the OR nurses indicating that they were comfortable speaking up and felt that their input was valued.
Debriefing

Standard MS.2.20
The management and coordination of each patients care, treatment, and services is the responsibility of a practitioner with appropriate privileges. Rationale Quality of care, treatment, and services is dependent upon coordination and communication of the plan of care and is given to all relevant health care providers to optimize resources and provide for patient safety. Practitioners have privileges that correspond to the care, treatment, and services needed by individual patients. Communication and coordination are keys to the safe management of patient care, treatment, and services. Communication among all practitioners and staff involved in a patients care, treatment, and services is vital to ensuring coordinated, high-quality care. Elements of Performance 1. Licensed independent practitioners with appropriate privileges manage and coordinate a patients care, treatment, and services. 2. A patients general medical condition is managed and coordinated by a physician. 3. The organized medical staff, through its designated mechanism, determines the circumstances under which consultation or management by a physician or other licensed independent practitioner is required. 4. Consultation is obtained for the circumstances defined by the organized medical staff. 5. There is coordination of the care, treatment, and services among the practitioners involved in a patients care, treatment, and services.

This technique allows a team to better prepare for the next encounter and avoid repeating the same mistakes. After a procedure is completed or at the end of the day, practitioners assess processes the team did well, challenges they faced, lessons learned, and what would be done differently the next time the opportunity presented itself. The more specific the debriefing, the more beneficial it could be.
MDRs

A multidisciplinary round (MDR) is a patient-focused communication system integrating care delivered by multiple providers using concurrent feedback, redundancy, and rapid cycle improvement. The fundamental goal of MDR is to enhance communication and

coordination among providers at the bedside. The Berkshire Medical Center used MDR to coordinate care and ensure adherence to evidence-based guidelines, specifically the American Heart Associations Get with the Guidelines Program, for all of its nonintensive care unit medical patients. Use of the MDR rapidly improved adherence to the guidelines, resulting in a 44.4% decrease in acute myocardial infarction (AMI) mortality, a 34.5% decrease in stroke mortality, and a 33.9% decrease in heart failure mortality.5 Moreover, this MDR model has been replicated in several other organizations through the Northeast. While large organizations can apply MDR on individual units to groups of 30 to 60 patients, smaller ones can apply it to their entire inpatient population.5

Similarly, implementation of a resident-centered MDR at the Norwalk Hospital was associated with a significant improvement in quality core measure performance in targeted areas of congestive heart failure from 65% to 76%, AMI from 89% to 96%, pneumonia from 27% to 70%, and all combined from 59% to 78%.6 Residents reported substantial improvement in core measure knowledge, systems-based care, and communication.
Multidisciplinary Team Meetings

Multidisciplinary teams benefit from concentrated time together to plan their roles and responsibilities, as well as to discuss opportunities for improvement in their work. Planned team meetings, scheduled weekly or monthly, are the most effective tool for accomplishing
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ACCREDITATION ESSENTIALS LINK

Maintaining Existing PrivilegesStandard MS.4.40

he ongoing professional evaluation of physicians and licensed independent practitioners is the primary method hospitals use to ensure that their clinicians have the necessary skills, knowledge, and attitudes to provide quality patient care. To that end, organizations should have in place clearly defined processes to facilitate such evaluations. These processes are important, as ongoing professional practice evaluation is factored into the decision to maintain, revise, or revoke a clinicians existing privileges (see Figure 1, page 8). In the past, practitioner assessments were conducted every two years as part of the reprivileging process. However, many organizations have now adopted a more proactive and systematic approach by scheduling quarterly departmental reviews.1
Who Performs the Evaluation?

Other organizations choose to have one medical staff oversight committee, which is chaired by the medical director or another medical staff leader. Leaders from each major department comprise the oversight committee that may include nonphysician members such as the vice president of operations or the nursing services director. In this scenario, if the committee finds practice trends that require further review, it typically refers them to the appropriate department for a more in-depth investigation. If conflicts of interest exist or the organization lacks staff members with sufficient subject-matter expertise, an external peer-review organization can be hired, or the organization can develop a collaborative arrangement with another local hospital to perform evaluations.
Criteria for Evaluation

ment form to evaluate their peers on an ongoing basis. The form covers the following performance elements2: Medical record keeping Outpatient care Inpatient care Clinical safety Support of the organization Resource management Performance improvement Interpersonal skills Communication skills Abusive behavior
Case Reviews

In some hospitals, each department has its own quality or peer review committee. At Tulsa, Oklahomabased Saint Francis Hospital, each of the 17 departments has its own Peer Evaluation and Patient Safety Committee, which performs its own evaluations.2 For the smaller departments, chart reviews are conducted after department meetings. Consequently, the whole department is, in essence, the review committee. Larger departments appoint from 5 to 10 physicians to serve on the committee. Individuals involved in this process should be trained in how to conduct objective and fact-based evaluations, as well as in using the appropriate scoring methodologies and other reporting tools.

The medical staff must choose and clearly define the information needed to make the determination that a practitioner does indeed provide safe, effective, and appropriate patient care. Criteria used in the ongoing professional practice evaluation may include the following: Review of operative and other clinical procedure(s)* performed and their outcomes Pattern of blood and pharmaceutical usage Requests for tests and procedures Length-of-stay patterns Morbidity and mortality data Practitioners use of consultants At the Emory Clinic, part of Emory Healthcare System in Atlanta, physicians use a performance assess-

* These include operative and other invasive and noninvasive procedures that place the patient at risk.

The medical staff should establish criteria for selecting case reviews, which are commonly used in evaluations. For example, case reviews can look at single incidents, evidence of a clinical practice trend, or both. This process should be used consistently across disciplines. In addition, a minimum case review requirement, such as 10%, should be established and applied uniformly across all departments. At Saint Francis Hospital, criteria for case reviews include clinical pertinence, medical record timeliness, and legibility.2 Although indicators used for review are determined by each department, they all measure return to the emergency room within 72 hours, return to the intensive care unit, or length of stay greater than three days following a vaginal delivery. It is imperative that the medical staff determine red flags to indicate when further investigation is necessary. Without these, the committee lacks direction on the appropriate action to take. If the criterion is an unexpected death, the red flag may be the lack of documentation of the patients deterioration during 48 hours preceding death, or the event may be related to a surgical procedure.

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Standard MS.4.40
Ongoing professional practice evaluation information is factored into the decision to maintain existing privilege(s), to revise existing privilege(s), or to revoke an existing privilege prior to or at the time of renewal. Elements of Performance The process for the ongoing professional practice evaluation includes the following: 1. There is a clearly defined process in place that facilitates the evaluation of each practitioners professional practice 2. The type of data to be collected is determined by individual departments and approved by the organized medical staff 3. Information resulting from the ongoing professional practice evaluation is used to determine whether to continue, limit, or revoke any existing privilege(s)

The intent of Standard MS.4.40 is for organizations to look at data on performance of practitioners with privileges in an ongoing manner rather than at the two year appointment process. This allows the practitioner to take the necessary steps to improve performance on a timely basis. The frequency of the evaluation can be defined by the organized medical staff, for example, every three months, six months, or nine months. Note: Every twelve months would be periodic rather than ongoing. It is important to remember that zero data is in fact data. Zero data can be measured as evidence-based good performance and is acceptable, for example, no infections, no complications, or no complaints. It is not acceptable to find that a practitioner has not performed a privilege for two years at the two year appointment process.

Aggregated Data

Aggregated performance measurement data, such as those set forth by The Joint Commission and the Centers for Medicare & Medicaid Services, are another source commonly used in these evaluations. These include adverse events, sentinel events, significant departures from generally accepted standards of practice, significant complications resulting either from a treatment or procedure, or procedures performed on the wrong patient or body site. The medical staff may opt to use compliance with the safe practices recommended by the Joint Commissions National Patient Safety Goals. It may consider looking at how well the practitioner complies with the current Centers for Disease Control and Prevention or World Health Organization hand hygiene guidelines; whether he or she accurately and completely reconciles medications across the continuum of care; or if the clinician uses the list of approved abbreviations, acronyms, symbols, and dose designations for medications.

Other relevant performance measurement data may be derived from activities that address infection control, risk management, and utilization review. Many associations, such as the Society for Thoracic Surgery, maintain registries with large databases of performance measurement projects that can be gleaned for data.
Discipline-Specific Data

unique to particular patient populations or interventions. Even if each department identifies discipline-specific criteria, it can look to the same measures being used throughout the organization. These may include mortality rates, complication rates, medication errors, health careassociated infection rates, and readmission rates.
Other Criteria

Keep in mind that some of these data may not be applicable to each and every clinician because they may cover specific conditions that not all physicians treat. Consequently, additional discipline-specific performance data may have to be incorporated into the criteria. The rate of physician compliance with surgical care improvement project criteria, surgical injuries, unplanned procedures not noted in the patients consent, wrong-site surgeries, and the incidence of postoperative deep vein thrombosis, are some examples of criteria that can be used in the surgery department. The medical staff may focus on events that are

In addition to case reviews and aggregated performance measurement data, the medical staff often use peer recommendations that come about through direct observation or discussions with other individuals involved in patient care, including consulting physicians, nurses, physician assistants, and administrative personnel. Additional information may be derived from the assessment of a practitioners interpersonal skills or professional behavior. In this case, patient/family complaints may be considered. Employing a tool such as the
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The Joint Commission: The Source March 2008 7

Accreditation Essential Link: Maintaining Existing PrivilegesStandard MS.4.40 Continued from page 7

Figure 1. Other Factors to ConsiderOngoing Professional Practice Evaluation

Does the organization have or plan to have the resources necessary to support the privilege? (Standard MS.4.00 Prior to granting of a privilege, the resources necessary to support the requested privilege are determined to be currently available, or available within a specified time frame.) Has the credential verification process established that the applicant has the licensure, training, education, and ability to perform the privilege? (Standard MS.4.20 The organized medical staff reviews and analyzes all relevant information regarding each requesting practitioners current licensure status, training, experience, current competence, and ability to perform the requested privilege.) Does focused professional practice evaluation validate competence? (Standard MS.4.30 The organized medical staff defines the circumstances requiring monitoring and evaluation of a practitioners professional performance.) Does data collected through the ongoing professional practice evaluation validate competency? (Standard MS.4.40)

Communication Assessment Tool, a 15-item instrument that has proven to be reliable and valid for measuring patient perceptions of a physicians interpersonal and communication skills,3 can help keep the assessment objective. Many medical specialty societies offer guidance on appropriate discipline-specific knowledge and skill levels for clinicians. For example, the American College of Surgeons defined a five-level model for verifying and documenting surgeons participation in educational programs and the surgeons knowledge and skills, including demonstration of satisfactory patient outcomes.4 The American College of Cardiology Foundation, the American Heart Association, and the American College of Physicians Task Force on Clinical Competence and Training developed recommendations intended to assist in assessing the competence of cardiovascular health care providers in practice and undergoing periodic review.5 The recommendations suggest that physicians perform a minimum of 50 examinations a year to maintain their expertise, plus 30 hours of continuing medical education over three years.
Intervention

tioners professional performance. The medical staff should follow that course of action, which should be defined in the bylaws. The clinician whose performance is being reviewed should be allowed to participate in the process as deemed appropriate by the medical staff. When the review committee at Saint Francis Hospital finds a deviation from the acceptable standard of care, the physician is contacted for input before it makes a final determination. The Source References
1. Understanding Focused and Ongoing Professional Practice Evaluations. AllMed Healthcare Management. http://www.allmedmed.com/ resources/articles/practice_evaluations.html. (accessed Dec. 14, 2007). 2. Joint Commission Resources: Credentialing and Privileging Your Medical Staff: Examples for Improving Compliance. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations, 2007. 3. Makoul G., Krupat E., Change C.H.: Measuring patient view of physician communication skills: Development and testing of the communication assessment tool. Patient Education and Counseling 67:333342, 2007. 4. Sachdeva A.K., Russell T.R.: Safe introduction of new procedures and emerging technologies in surgery: Education, credentialing, and privileging. Surg Clin N Am 87:853866, 2007. 5. American College of Cardiology Foundation/American Heart Association: 2007 Clinical Competence Statement on Vascular Imaging with Computed Tomography and Magnetic Resonance. Circulation 116:13181335, 2007. http://circ.ahajournals.org (accessed Dec. 14, 2007).

The medical staff should delineate the course of action to be taken when an evaluation reveals a question about the practi-

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SPOTLIGHT ON SUCCESS

Seton Family of Hospitals Improves Perinatal Care

Complying with the Improving Organization Performance Standards PI.3.10 and PI.3.20 in 2008
(Reducing the possibility of a bad outcome is important to improving safety and performance. One important factor in improving performance requires effective reduction of components that could contribute to adverse events and/or outcomes. Unanticipated adverse events and/or outcomes are sometimes experienced through poorly designed systems, system failures, or errors. Through organizational leadership implementation and collaborative plan efforts, complying with The Joint Commissions Improving Organization Performance standards (PI.3.10 and PI.3.20) can prove to be effective in achieving your organizations goals and initiatives. Heres how Seton Family of Hospitals became a 2007 Ernest Amory Codman Award winner by using performance improvement methods.)

or nearly 10 years, organizations across the country have been working diligently to reduce preventable medical errors and improve the safety and quality of care they provide. One such organization is Ascension Healtha large, Catholic, nonprofit health system with a network of more than 75 acute care, long term care, and other health care facilities in 20 states and the District of Columbia. In 2003 Ascension set a goal for its entire system to eliminate preventable patient deaths by 2008 across all populations. To achieve this goal, the organization needed to implement a culture shift and transform the care provided in its facilities. A first step to achieving this goal was to identify seven high-risk, high-volume diagnostic categories and patient care areas in which preventable patient

deaths were more likely to occur. By eliminating preventable deaths in these areas, Ascension believed it could achieve significant progress in meeting its ultimate goal. Ascension charged several of its organizations to serve as alpha sites for improvement, encouraging them to develop transformational practices that could eliminate patient harm and prevent death within one or more of the seven areas. The Seton Family of Hospitals, a health care network in the Ascension system, was asked to serve (along with two other Ascension ministries) as an alpha site for the high-risk area of perinatal safety. As a first step to improving perinatal safety and eliminating preventable birth trauma, Seton formed an interdisciplinary work team, called the Perinatal Safety (PNS) team. This group had representation from all four

of Setons hospitals that provided obstetrical services. Made up of a variety of disciplines, including medical staff, nursing staff, and organization leadership, the goal of this team was to spearhead the perinatal safety initiative and champion change efforts.
Focusing on Evidence-Based Practices

Organization Facts: Seton Family of Hospitals is a nine-hospital health system headquartered in Austin, Texas. As part of the Ascension Health system, Seton Family of Hospitals has more than 10,000 employees, and services 11 counties with a population of 1.7 million people throughout central Texas. Program Description: Seton Family of Hospitals engaged in an initiative to improve perinatal safety and eliminate preventable birth trauma within its facilities. The organization implemented evidence-based and consensus-based practices, and used small tests of change to improve performance and eliminate preventable errors. Outcomes: As of 2006, the organization reduced the rate of preventable birth trauma by 93%. As a result of the initiative, the organization also reduced the number of admissions to the neonatal intensive care unit and patient length of stay.

With the help of the Institute for Healthcare Improvement (IHI), the PNS team researched and investigated evidence-based practices regarding perinatal safety and preventable birth trauma. Unfortunately, when we started, we could not find any preexisting change package of best practices in the obstetrical area for us to work from, says Frank Mazza, M.D., vice president of medical affairs at Seton Medical Center, the largest of Seton Family of Hospitals. In some cases, when established best practices didnt exist, the PNS team needed to develop best practices via consensus with all relevant stakeholders, test the best practices on a small scale, and then implement the ones that were effective in driving improvement on a broader basis. Seton used the Plan-Do-StudyAct model of rapid cycle change to test and implement both evidence-based and consensus-based practices. To focus its efforts, Seton reviewed literature and determined the five areas
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Spotlight on Success: Seton Family of Hospitals Improves Perinatal Care Continued from page 9

of highest risk for obstetrical harm. We zeroed in on these areas, feeling that if we could eliminate preventable trauma, we would be well on our way to achieving our ultimate goal, says Mazza. Following are the five critical areas: Failure to recognize fetal distress/nonreassuring fetal status Failure to effect a timely caesarean (C-section) birth Failure to properly resuscitate a depressed baby Inappropriate use of oxytocin/ misoprostol Inappropriate use of vacuum/forceps For each of these five areas, we applied evidence-based practice where it existed, and developed consensus-based approaches where evidence-based practices were not available, says Mazza. In designing new processes, we followed the principles of standardization, simplification, and built-in redundancy. Following are some of the many interventions the organization implemented: Adopted the National Institute of Child Health and Human Developments common language for nurses and physicians to use in the labor and delivery setting when discussing fetal heart rate monitoring. Conducted interdisciplinary conferences in which nurses and physicians analyzed fetal heart rate strips. In the context of the labor and delivery unit, where the frequency of serious adverse events is low but risk to mother and infant is high, we found that interdisciplinary fetal heart monitor strip review sessions offered realistic, risk-free environments to examine practices and reinforce skills that develop and promote teamwork and communication, says Mazza. Created a customized Situation BackgroundAssessmentRecommendation communication tool to help

nurses and physicians communicate in the labor and delivery unit. This tool helps structure communication and ensures that the appropriate information is consistently and accurately shared every time communication takes place. Developed, in conjunction with the other Ascension alpha sites and the IHI, a consensus-based practice regarding the use of the high-risk drug oxytocin, which is used to induce or augment labor. The elements of this practice included performing and documenting the following: Reassuring fetal status Examination of the cervix within one hour before or after start of oxytocin Absence or active management of uterine hyperstimulation with increases in oxytocin Documentation of gestational age > 39 weeks, or estimated fetal weight, depending on whether oxytocin was used to electively induce a patient or augment contractions Eliminated the practice of electively inducing labor prior to 39 weeks gestation. Oftentimes a patient is electively induced early because it is more convenient for the physician or the mother. The physician may be leaving town, or the mother may want to coordinate the delivery with plans that her family has made to help support the new baby, says Mazza. However, based on our literature review, as well as our own internal data, we believed that electively inducing a patient prior to 39 weeks could lead to an increased risk of birth trauma and injury. By eliminating this practice, we hoped to effect a reduction in our birth trauma rate. Implemented evidence-based practices regarding the use of vacuum

devices and forceps during the second stage of labor. These practices restricted when vacuum tools and forceps could be used and required physicians to document the following in the medical record: The indications for instrumental delivery The estimated fetal weight relative to the size of the maternal pelvis The presentation and station of the fetal head Empowered bedside and scheduling staff to stop the line when deviations from best practice were encountered. For example, if a physician calls to schedule an induction, and the patient is only 38 weeks along, the scheduler is empowered to say no to the physician. The physician can feel free to move up the chain of command, but the answer will still be no, says Mazza.
Measuring Success

As Seton developed and implemented its transformational practices, the organization created both process and outcome measures to monitor change and measure success. Process measures determine whether processes and procedures are being followed, such as whether physicians are refraining from elective inductions prior to 39 weeks, or whether instrumented deliveryassociated best practices are followed.

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Outcome measures examine the actual outcomes of processes, such as the incidence of premature births associated with electively induced labor and the incidence of birth trauma associated with the use of vacuum/forceps. The ultimate outcome measure that Seton examined was the number of birth traumas that occurred per 1,000 births.
Lessons Learned

In implementing this initiative, Seton learned that effective performance improvement results from interdisciplinary collaboration. Because multiple specialtiesnurses, doctors, administrators, and so forthwork in the same space, any performance improve-

ment must involve input and commitment from all these areas, says Mazza. The organization also realized the value of using data to drive performance improvement. Like any organization, we received some push back from staff and physicians about implementing many of our new processes. By sharing improvement data with staff and physicians, it helped show the value of the improvements, and got more people on board, says Mazza.
Achieving Success

Seton Family of Hospitals has achieved dramatic improvements in perinatal care. Over the course of the program, Seton reduced its birth trauma rate by

93%, from 0.3% in 2001 (a number that already represented half the national average) to 0.02% in 2006. Over the past four quarters, the birth trauma rate has dropped to zero. The organization has also reduced its use of vacuum and forceps, reducing its instrumental delivery rate from 7.4% to 4.7%, and eliminated elective inductions prior to 39 weeks. Seton also decreased prematurity rates from 0.25% to 0.16%. The organization achieved this transformation in care as a result of continual enhancements to care management accomplished through repeated small tests of change, and the use of evidencebased and consensus-driven obstetrical practices. The Source

Accreditation Essentials: Medical Staff Communication: Cornerstone of Care CoordinationStandard MS.2.20 Continued from page 5

these types of activities that are essential to quality patient care.4 One hospital found that the implementation of multidisciplinary team meetings yielded improved communication and enhanced quality of care. For starters, it allowed for practitioners from various disciplines to develop a common language used verbally and in written reports. When a mutually agreed upon terminology was used, it enhanced communication between the disciplines.7 In addition, as medical technology continues to advance, the choice of investigation and the interpretation of results are more complex. Thus, the meetings served as a venue for practitioners to update each other regarding technology and continuing professional development. Such interactions added quality to the diagnosis, disease staging, and patient management decisions.
Medical Emergency Teams

safety by preventing the loss of crucial medical information and promoting the sharing of relevant information at the correct time in the most efficient manner. Best of all, these techniques work in all types of health care organizations, particularly those that have embraced a multidisciplinary approach to patient care. The Source References
1. Leonard M., Graham S., Bonacum D.: The human factor: The critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care 13 (Suppl 1):18590, 2004. 2. Leonard, M.: The Human Factor: Teamwork and Communication in Patient Safety. http://www.mihealthandsafety.org/2004_conference/ Leonardslides.ppt (accessed Jan. 4, 2008). 3. Ohlinger J., et al.: Evaluation and development of potentially better practices for perinatal and neonatal communication and collaboration. Pediatrics 118:S147S152, 2006. http://www.pediatrics.org/cgi/ content/full/118/Supplement_2/S147 (accessed Jan. 1, 2008). 4. Institute for Healthcare Improvement: Use Regular Huddles and Staff Meetings to Plan Production and to Optimize Team Communication. http://www.ihi.org/IHI/Topics/OfficePractices/Access/Changes/ IndividualChanges/UseR GET REST (accessed Dec. 19, 2007). 5. Ellrodt G., et al.: Multidisciplinary Rounds (MDR): An implementation system for sustained improvement in the American Heart Associations Get with the Guidelines Program. Critical Pathways in Cardiology 6(3):106116, 2007. 6. OMahony S., et al.: Use of multidisciplinary rounds to simultaneously improve quality outcomes, enhance resident education, and shorten length of stay. J Gen Intern Med 22(8):10731079, 2007. 7. Kane B., et al.: Multidisciplinary team meetings and their impact on workflow in radiology and pathology departments. BMC Medicine. 5:15, 2007. http://www.biomedcentral.com/1741-7015/5/15 (accessed Jan. 4, 2008).

This multidisciplinary team is designed to respond to staff concerns about a patients health. When a patient experiences a change in status, staff calls the medical emergency team (MET) to check the patient and take the necessary action. Typically the MET is activated if the patient experiences an acute change in heart rate, blood pressure, respiratory rate, pulse oximetry saturation despite oxygen administration, conscious state, or urine output. Structured communication techniques have been proven to promote effective communication, which enhances patient

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Call for Applicants John M. Eisenberg Patient Safety and Quality Awards
On February 1, 2008, The Joint Commission and The National Quality Forum (NQF) began accepting applications for the John M. Eisenberg Patient Safety and Quality Awards for 2008. The John M. Eisenberg Patient Safety and Quality Awards recognize the achievements of individuals who have made significant and lasting contributions to improving patient safety and health care quality and individuals and organizations who, through a specific initiative or project, have made an important contribution to patient safety and health care quality. The awards program provides an opportunity for individuals and/or organizations to receive national recognition for their ongoing contributions to patient safety and quality of care. This memorial awards program was created jointly by NQF and The Joint Commission and named for John M. Eisenberg, director of the Agency for Healthcare Research and Quality and a member of the founding Board of Directors of NQF. It honors the enduring contributions of this impassioned advocate of health care quality improvement, who passed away in March 2002. Awards are available annually in the following categories: Individual Achievement Innovation in Patient Safety and QualityNational Innovation in Patient Safety and QualityLocal Research The awards will be presented in conjunction with NQFs Annual National Policy Conference on Quality in Washington, D.C., on October 1516, 2008. Additional information about the award and the award application form are available on The Joint Commission Web site (http://www.jointcommission.org) and the NQF Web site (http:// www.qualityforum.org).

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