4 Why Change?#1: Decrease the time required #2: Ensure detection of deficient practices that affect patient outcomes #3: Promote a culture of safety
5 What Are The Differences? CoreOrganized by taskCovers all CfCPre survey data reviewRequires:Review of Administrative records if triggeredBasicOrganized by taskCovers all CfCPre survey data reviewRequires:Review of selected:Administrative recordsContractsAgreements
6 What Is A Trigger? Indicates potential deficient practice Citation or further investigation is warrantedExamples:“Dummy” drip chamberCovered accessDisrespectful communicationEquipment not calibrated as requiredAbsence of a functional IDT that monitors, recognizes and addresses barriers to attainment of identified outcome goals
7 What Are The Differences? BasicRequires:Review of selected:Personnel recordsQAPIClinical recordsObservations of care delivery and water/dialysate safetyInterviews of patients, direct care staff and support staff (MD, MSW, RD, Nurse Manager)CorePriority:“Flash” observations of careTreatment areaWater/DialysateHome therapiesReuseIs there a “Culture of Safety?”
9 Culture of Safety: Open Communication TransparencyHigh comfort level with questions and answersAll levels of staff included “in the know”No surprisesChanges discussed before being madeReasons for decisions are clear
10 Culture of Safety: Patient Engagement Questions from CMS Patient Interview Guide:How do the staff at this facility encourage you to give input? If you had a complaint, how would you file it here or elsewhere?How do staff encourage you to participate in care planning and consider your needs, wishes and goals? How do staff help you address barriers to meeting goals (targets)? Do staff discuss changes in your prescription before making them?
11 Culture of Safety: Engagement Ideas for PatientsEngage during roundsDetect adverse eventsEmpower patients to speak up for safe careInclude patient inputIdeas for StaffInclude all levels in improvement teamsReward reportingAudit teamsReward ideas to improve safety
12 Culture of Safety: Clear Expectations for Staff Role descriptions are clearPolicies and procedures are up-to-date“There is a right way, staff know that right way, and staff do their assigned work the right way.”--Glenda Harbert,ESRD Network of Texas
13 Culture of Safety: Reporting Without Fear Reporting rewardedErrors and “good catches”Patient and staff complaintsNon-punitive responses to adverse events/errorsIf you use shame and punishment of all errors:System vulnerabilities won’t be identifiedErrors will be concealedAccountability is balanced by a “just culture”Barnsteiner (2011) Teaching the culture of safety. OJIN: The Online Journal of Issues in Nursing. 16(3) Manuscript 5.
14 “Just Culture” An atmosphere of trust People are encouraged/rewarded for reportingThere is a line between acceptable/non-acceptable behaviorMeadows, S. (2005)
15 Types of Errors Inadvertent or simple human error At risk behavior Reckless behavior
16 Simple Human ErrorExample: a nurse or PCT forgets to turn the blood pump to the prescribed blood flow rate at the beginning of treatmentManagement response: Console the PCT/nurse; consider ways to simplify task, improve trainingGreenspan, B. (2015) Core Curriculum for Nephrology Nursing, 6th Edition, in process
17 At Risk BehaviorExample: a nurse or PCT, in the interest of time, leaves her first patient at a 200 BFR until she completes the initiation of all her patients. She then returns to set all the blood pumps to the prescribed blood flow rate, resulting in decreased adequacy of treatment for each patient where the ordered BFR was delayed.Management response: Coach the nurse/PCT; improve leadership messaging regarding the risks of decreased patient outcomes.Greenspan, B. (2015) Core Curriculum for Nephrology Nursing, 6th Edition, in process
18 Reckless BehaviorExample: a nurse or PCT comes in angry, leaves all her patients at a 200 BFR for the whole shift and does not monitor her patients’ status during the treatment, resulting in decreased adequacy for all four patients and a drop in blood pressure for one patientManagement response: Zero tolerance; remedial action; review vulnerabilities in supervisionGreenspan, B. (2015) Core Curriculum for Nephrology Nursing, 6th Edition, in process
19 Decision Tree Were the actions intended? Does there appear to be ill health or substance abuse?Did the individual break protocol or procedure? Have access to protocol and needed supplies? Choose to act off protocol to reduce risk?Would a comparably educated and experienced person be likely to behave the same way in similar circumstances? If not, were there deficiencies in training or supervision?Meadows, S. (2005)
21 What Are The Differences? BasicGuidance suggests use of data to focus surveyClinical record reviewComplete for part of sampleQAPI reviewSeparate reviewCoreRequires use of data to focus surveyClinical record reviewFocused reviewsQAPI ReviewIntegrated throughout
22 Core Survey “Themes” Data Use Infection Control QAPI Focus the survey Use checklistsMake more observationsQAPIFunctional, effective programRequired internal audits replace survey tasks
23 Core Survey “Threads” “Culture of Safety” Safety of Dialysis Delivery Operation, maintenance & monitoring of dialysis technical systems:Water/dialysateReprocessingDialysis delivery equipment/systemsPatient VoiceListening to patient’s point of viewAn environment where patient input is welcomed
24 Patient Engagement Review Patient health outcomes-physical and mental functioning review: To verify that the facility QAPI Team is focused on patients’ psychosocial status by regular monitoring through the administration and use of a standardized survey that assesses the patients' physical and mental functioning.Ask: How do you track and trend eligible patients' scores in an age-appropriate standardized physical and mental functioning survey, e.g., KDQOL-36? What is your facility’s threshold for patients completing and refusing the survey annually? Note: Although it is expected that a few patients may refuse to participate in the assessment of their physical and mental functioning, high refusal rates, e.g., >20% would indicate a problem which should be recognized and addressed by the QAPI Team.Review the QAPI documentation related to patient physical and mental functioning outcomes monitoring.Does the facility’s QAPI Team track and trend the % of eligible patients who complete and refuse the physical and mental functioning survey? Does the facility’s QAPI Team track and trend the scores on a facility level? ☐Yes ☐No (V628)-ExplainIf the trends of facility level scores showed a decline or the refusal rate increased, is there evidence that the facility’s QAPI Team recognized a problem existed, investigated the possible causes, and took meaningful actions to address the issue(s) and attain improvements? ☐Yes ☐N/A ☐No (V628)- ExplainCMS QAPI tool, page 9 of 10
25 What Are The Differences? BasicCompletion not definedMay be cited for “work in progress”CoreComplete when all triggers investigatedLower level citation if problem has beenRecognized andAdequately addressed by QAPI
27 Observe Pay attention to practice Direct care delivery Medication preparation and administrationWater treatmentStart upTestingDialysate preparation
28 Ask Interview people doing the work Nurses Patient care technicians DietitiansSocial workersPhysiciansBiomedical staff
29 Ask Interview patients and families In person/by phone Potential questions:How do staff encourage you to give input to your care here?Have you ever or do you feel you could speak up about something you felt was unsafe?Do you see staff cleaning hands and changing gloves?
30 Review Dialysis Facility Reports Clinical records Laboratory reports: aggregate and specificOperational logsQAPI materialsPersonnel recordsPhysician credential files
31 How To Prevent Negative Findings Infection Control (7 of top10 nationally-2013)Expectations have changedCDC focus: medication administration; initiation /termination of treatment; “scrub the hub”Patient/station treated separatelySelf audits expected/requiredEducateAudit practiceRepeatCelebrate success!
32 How To Prevent Negative Findings Physical Environment (# 3 nationally--2013)Access visible: patient engagement criticalEnvironmental rounds:Make them REALTake action promptlyEquipment:Functional system to stay current with PMAudit record keeping systemReport in QAPI
40 Selected ReferencesBarnsteiner (2011) Teaching the culture of safety. OJIN: The Online Journal of Issues in Nursing. 16(3) Manuscript 5. doi: /ojin.Vol16No03Man05Greenspan, B. (2015) Core Curriculum for Nephrology Nursing, 6th Edition, in processGregory, B. & Kaprielian,V. (2005). Anatomy of an error. Retrieved March 1, 2014 fromInstitute of Medicine (1999) To Err is Human. available at
41 Selected ReferencesLevinson, D. (2012). Hospital incident reporting systems do not capture most patient harm. Report from the Office of Inspector General. Retrieved March 1, 2014 from https://oig.hhs.gov/oei/reports/oei pdfMeadows, S., Baker, K., & Butler, J. (2005). The incident decision tree: guidelines for action following patient safety incidents. In Henricksen, K., Battles, J., Marks, E. et al. (Eds). Advances in patient safety; from research to implementation: Vol 4 Programs, tools, and products. Rockville (MD): Agency for Healthcare Research and Quality Last retrieved from
42 Selected ReferencesReason, J. (1997). Managing the risks of organizational accidents. Aldershot: AshgateTaylor, J. (2010). Safety culture: Assessing and changing the behavior of organizations. Surrey, England: Gower Publishing Limited