1. Patient Safety Initiative (PSI): Hospital Survey Protocol Russ Forney, PhD, MT(ASCP) Licensing & Surveys, Aging Division Wyoming Department of Health (Photos courtesy of Cinderella Forney)

2. Sizing Up the Situation Adverse events 1 in 3 admissions (2011) Adverse events 1 in 3 admissions (2011) HAIs affect 1 in 20 inpatients HAIs affect 1 in 20 inpatients About 1 in 5 Medicare patients readmitted within 30 days of discharge About 1 in 5 Medicare patients readmitted within 30 days of discharge 1.8M injuries, $35B in 3 years (08-11) 1.8M injuries, $35B in 3 years (08-11) Survey process has little impact Survey process has little impact

3. Partnership for Patients P4P: focused on improving patient safety in hospitals P4P: focused on improving patient safety in hospitals Reduce HAC = reduce readmissions Reduce HAC = reduce readmissions Partners: HHS, FDA, CDC, VA, HENs, QIOs, National and State associations, professional societies Partners: HHS, FDA, CDC, VA, HENs, QIOs, National and State associations, professional societies

4. H EAD SCRATCHING …

5. Patient Safety Initiative (PSI) PSI emerged from P4P PSI emerged from P4P CMS S&C initiative CMS S&C initiative Tools for surveyors & facilities Tools for surveyors & facilities Focus on infection control, discharge planning, and QAPI activities Focus on infection control, discharge planning, and QAPI activities

6. Approaching a Solution 4,000 member organizations (“partners”) 4,000 member organizations (“partners”) Goal: Reduce readmissions Goal: Reduce readmissions Tools to assist hospitals and surveyors Tools to assist hospitals and surveyors Common to certification & accreditation (“substantial equivalent”) Common to certification & accreditation (“substantial equivalent”) Adopted focus: IC, DC, QAPI Adopted focus: IC, DC, QAPI

7. R USS GOES TO B ALTIMORE …

8. … AND SO DOES P AT

9. PSI & Pilot Surveys Acute Care Hospital survey process Acute Care Hospital survey process Emphasize 3 CoPs: Emphasize 3 CoPs: QAPI QAPI Discharge planning Discharge planning Infection Control Infection Control Regulations unchanged, build better surveyors Regulations unchanged, build better surveyors

10. Initial Impact Pilot surveys (field training) Pilot surveys (field training) No increase in staffing No increase in staffing Tools guide survey process Tools guide survey process Tools identify specific tags Tools identify specific tags Enhance depth, consistency of surveys Enhance depth, consistency of surveys

11. Tool-guided Survey Protocol CoP specific survey tools CoP specific survey tools Underlying CoP not changed Underlying CoP not changed Better identify noncompliance and “best fit” tag Better identify noncompliance and “best fit” tag Target minimum acceptable health & safety standards Target minimum acceptable health & safety standards

12. Pilot Survey “Rules” Initiate complaint survey (CMS 2802) Initiate complaint survey (CMS 2802) No conditions (other than IJ) No conditions (other than IJ) One CoP (tool) per survey One CoP (tool) per survey Training in the field (OJT) Training in the field (OJT) Share surveyor tools with facilities Share surveyor tools with facilities

13. A M ATTER OF P ERSPECTIVE …

14. The Survey Process Verify compliance through: Observation, interview, review Observation, interview, review Patient driven protocols Patient driven protocols Facility-relevant projects Facility-relevant projects Hospital-wide processes Hospital-wide processes Apply the surveyor tools within the existing framework

15. Wyoming PSI Pilot Surveys Mountain View Regional Hospital Mountain View Regional Hospital 13-16 August: Russ, Pat, Janelle, Linda 13-16 August: Russ, Pat, Janelle, Linda Infection control surveyor tool Infection control surveyor tool Ivinson Memorial Hospital Ivinson Memorial Hospital 20-22 August: Pat, Tony, Karen 20-22 August: Pat, Tony, Karen Discharge planning surveyor tool Discharge planning surveyor tool Lander Regional Hospital Lander Regional Hospital 10-11 September: Russ, Pat, Lori, Larry 10-11 September: Russ, Pat, Lori, Larry QAPI surveyor tool QAPI surveyor tool

16. Infection Control Worksheet 5 Modules, 42 pages 5 Modules, 42 pages 2 surveyors x 2 days 2 surveyors x 2 days Cover all practices to identify & prevent HAIs Cover all practices to identify & prevent HAIs Follow patients through procedures & treatments Follow patients through procedures & treatments

17. Infection Control Pilot More in-depth investigation than current protocol More in-depth investigation than current protocol No “experts”, but similar outcomes No “experts”, but similar outcomes Heavily weighted on processes & monitoring activities Heavily weighted on processes & monitoring activities Vertical elements Vertical elements

18. Discharge Planning Worksheet 4 Sections, 23 pages 4 Sections, 23 pages 2 surveyors x 1-2 days 2 surveyors x 1-2 days Cover best practices for discharge planning & coordination of care Cover best practices for discharge planning & coordination of care All healthcare members involved All healthcare members involved

19. Discharge Planning Pilot Planning begins at admission Planning begins at admission Ongoing throughout admission Ongoing throughout admission Address patient needs post-discharge Address patient needs post-discharge Physician involvement Physician involvement Results in reduced readmissions Results in reduced readmissions

20. QAPI Worksheet 6 Parts, 21 pages 6 Parts, 21 pages 2 surveyors x 1-2 days 2 surveyors x 1-2 days Quantitative assessment (data-driven) Quantitative assessment (data-driven) Follow specific projects & activities through entire life-cycle Follow specific projects & activities through entire life-cycle Required elements: med errors, inf cont, transfusions, near-miss/adverse events Required elements: med errors, inf cont, transfusions, near-miss/adverse events

21. QAPI Pilot QAPI is relevant to the hospital QAPI is relevant to the hospital Involvement through the ranks Involvement through the ranks Data as basis for analysis (CDC) Data as basis for analysis (CDC) Interventions & ongoing assessment Interventions & ongoing assessment All programs, units, & services All programs, units, & services

22. CMS Update 187 pilot surveys, 52 State Agencies 187 pilot surveys, 52 State Agencies Sep 2011 to Sep 2012 Sep 2011 to Sep 2012 Less P&P, more observations of activity Less P&P, more observations of activity Sorting out regulation vs best practice Sorting out regulation vs best practice Links surveyors and staff more closely Links surveyors and staff more closely Continue in Fiscal Year 2013…? Continue in Fiscal Year 2013…?

23. W HO ELSE IS IN THE R IVER …

24. Wyoming Partners Mountain-Pacific Quality Health (QIO) Mountain-Pacific Quality Health (QIO) WY Hospital Association WY Hospital Association WY Dept of Health WY Dept of Health WY HAI Advisory Group WY HAI Advisory Group HAI Coordinator HAI Coordinator HLS HLS WY ASC Association (IC initiatives) WY ASC Association (IC initiatives)

25. Contact: Russ Forney, PhD, MT(ASCP) Healthcare Licensing & Surveys Aging Division, WY Dept Health russ.forney@health.wyo.gov307-777-7123 “Preferred” Contact: Patricia (Pat) Prince, RN pat.prince@wyo.gov307-777-7123

26. Q UESTIONS ?