1 © 2005 TMIT The Patient Safety Officer Executive Training Course Charles Denham, M.D Leapfrog NQF Safe Practices Program.

4 © 2005 TMIT Leapfrog Mission Trigger giant leaps forward in the safety, quality and affordability of health care Informed health care decisions - Surveys High-value health care through P-4-P Programs 24 “Roll-Out” Regions to arrive at aggressive but feasible targets

8 © 2005 TMIT Safe Practice Background “National Quality Forum Safe Practices for Better Healthcare: A Consensus Report” was developed to help standardize evidence-based safe practices of care. The Leapfrog NQF Safe Practices ‘Leap’ is using these safe practices to survey hospital performance

10 © 2005 TMIT The Leapfrog NQF Safe Practices ‘Leap #4’ NQF endorsed 30 high-priority Safe Practices to be universally applied in relevant clinical care settings Includes Leapfrog’s initial 3 safe practices Leapfrog will now assess hospitals’ progress on the remaining 27 safe practices

11 © 2005 TMIT Development of this New Survey Survey Tool developed by Texas Medical Institute of Technology (TMIT) 27 practices weighted according to patient safety impact, combined into a single score (1,000) Relative ranking compared to other hospitals - placed into quartiles

© 2003 TMIT Leapfrog Survey 1.0. 11.17.03 1600 CT 15 Enterprise-wide System #PracticeFinal Weighting out of 1,000 points 1Create Safety Culture263 3Ensure Adequate Nursing Workforce119 SUBTOTAL382 Enterprise-wide Process 6Verbal Order Readback36 7Standardized Abbrev./Doses17 8No Pt Care Summaries from Memory17 9Pt Care Info/Orders to all Providers84 SUBTOTAL154 TOTAL ENTERPRISE-WIDE536 Clinical Care Setting or Function Specific 5Pharmacist Active in Med Use32 10Pt Readback of Informed Consent9 11Document Resusc./End of Life/ Directives12 13Prevention of Mislabeled Radiographs16 14Wrong-site/Wrong-patient Prevention30 15Prophylactic Beta Blockers for Elective Surgery23 16Pressure Ulcer Prevention28 17DVT/VTE- Risk Assessment & Prevention27 18Anticoagulation Services39 19Aspiration Prevention24 20Central Venous Line Sepsis Prevention33 21Surgical Site Infection/AB Prophylaxis37 22Contrast-induced Renal Failure Protocol12 23Malnutrition Prevention12 24Tourniquet—Ischemia/Thrombosis Prevention9 25Hand Washing33 26Flu Vaccination for HC Workers11 27Optimize Medication Workspaces7 28Optimize Med. Storage/Pkg/Labeling22 29I.D. High Alert Medications21 30Med. Unit Dosing/Unit-of-Use Dispensing29 SUBTOTAL465 27 NQF Safe Practices Weighting Results 1,000 Points Applied to 27 Practices Weighted Individually Hospitals Nationally Ranked

© 2003 TMIT Leapfrog Survey 1.0. 11.17.03 1600 CT 16 Enterprise-wide System # PracticeFinal Weighting out of 1,000 points 1Create Safety Culture263 3Ensure Adequate Nursing Workforce119 SUBTOTAL382 Enterprise-wide Process 6Verbal Order Readback36 7Standardized Abbrev./Doses17 8No Pt Care Summaries from Memory17 9Pt Care Info/Orders to all Providers84 SUBTOTAL154 TOTAL ENTERPRISE-WIDE536 27 NQF Safe Practices Weighting Results

© 2003 TMIT Leapfrog Survey 1.0. 11.17.03 1600 CT 17 Clinical Care Setting or Function Specific 5Pharmacist Active in Med Use32 10Pt Readback of Informed Consent9 11Document Resusc./End of Life/ Directives12 13Prevention of Mislabeled Radiographs16 14Wrong-site/Wrong-patient Prevention30 15Prophylactic Beta Blockers for Elective Surgery23 16Pressure Ulcer Prevention28 17DVT/VTE- Risk Assessment & Prevention27 18Anticoagulation Services39 19Aspiration Prevention24 20Central Venous Line Sepsis Prevention33 27 NQF Safe Practices Weighting Results

© 2003 TMIT Leapfrog Survey 1.0. 11.17.03 1600 CT 18 Clinical Care Setting or Function Specific 21Surgical Site Infection/AB Prophylaxis37 22Contrast-induced Renal Failure Protocol12 23Malnutrition Prevention12 24Tourniquet—Ischemia/Thrombosis Prevention9 25Hand Washing33 26Flu Vaccination for HC Workers11 27Optimize Medication Workspaces7 28Optimize Med. Storage/Pkg/Labeling22 29I.D. High Alert Medications21 30Med. Unit Dosing/Unit-of-Use Dispensing29 SUBTOTAL465 27 NQF Safe Practices Weighting Results

19 © 2005 TMIT 1.Compliment the NQF Safe Practices Report (May 2003): The survey, weighting system, and ranking system designs are explicitly tied to the problem areas and practices defined by the NQF report. Recognizing the challenges of tying standards, measures, or practices to a report that is written at a snapshot in time, the survey, weighting, and ranking systems take into account that new evidence and refinement of performance improvement methods are being generated all the time. Patient safety is an emerging science and is constantly evolving. Therefore, the guiding principles included focus on the excellent list of safety problems being targeted by NQF practices and apply the “4 A Framework” below. The “4 A Framework” provides real flexibility of interpretation and provides a means of providing partial credit for partial progress and partial credit for commitment to progress. Although the survey will undergo refinement through public review and optimization by our subject matter experts, the design will be kept intact in order to make the survey fair and reasonable. The goal is to neutralize the challenges of explicitly tying questions to specific language of practices that are evolving while staying well within the scope of the NQF report. 2.Partial Credit for Partial Progress: The questions were designed using a “select any that apply” response giving hospitals numerous opportunities for partial credit. Once significant public input is provided, a set of FAQs will be provided for each question to assure that respondents will have clarity regarding what will qualify for credit on a question specific basis. 3.Partial Credit for Commitment: Many of the questions provide partial credit to organizations that make substantial commitment to get started. This will help those that may be “behind the safety curve”. The intent is to provide a clear roadmap to organizations that have heretofore not prioritized safety. These questions are also intended to provide fairness in areas where patient safety issues have not been well publicized. 4.Systematic Application of 4A Framework : The 4A framework recognizes the sequential and interdependent nature of awareness of our performance opportunities, accountability of leadership, the ability to employ practices, and measurable action towards closing performance gaps. This “4A Framework” (updated from a 3 A framework published by C. Denham in 2001) was used as an organizational structure to allow systematic customization of survey questions. Awareness: Clearly, the leaders of an organization must be aware of performance problems before they can make any impact on them. The concept of THE problem or performance opportunity addresses the awareness by hospitals that there is evidence to support a common problem across all hospitals. The concept of OUR problem addresses awareness of the frequency and severity of adverse events to our patient population within our organization and recognition of the impact that practices or performance improvement methods can have on those adverse events. Awareness of THE performance opportunities and OUR performance opportunities are addressed in a relatively standardized manner in each survey question, however they were customized to each problem depending on the current state of awareness in the community. Accountability: A critical success factor to patient safety is accountability of the leadership to performance. Whether the mechanisms of personal performance reviews or performance compensation incentives are used, sustained gains in patient safety frequently do not occur without personal accountability of the leaders. This issue was addressed in a relatively standardized way throughout the survey, however the questions were fine tuned to the scope or care setting addressed by the practice. Ability: An organization may be aware of THE problem – a performance gap common to most hospitals. In fact they may be aware of OUR problem (their own) with clear evidence of frequency and severity of adverse events in their own patient population. They may even have awareness of the impact of a given practice, however if they do not invest in education or skill development and more importantly allocate real protected staff time and dollars to a given problem, the impact on safety is modest at best. Adding a patient safety responsibility to an already overloaded employee without carving out the time and providing them the necessary financial resources to make an impact sends a clear message to the organization. The “ability” related survey questions employ a graduated set of investment levels ranging from investment in education, skill development (training regarding the application of practices or performance improvement methods), dedicated HR, and dedicated line item budget allocations. Actions: Action activities were tied to the NQF cited best practices language as appropriate. Where there have been great strides in best practices, the survey questions provide latitude for activities deserving credit. A set of FAQs will be tied to each survey question that will provide guidance as to what activities may qualify for credit, especially if certain developments in patient safety have been substantiated in the literature after publication of the NQF report. Performance Improvement programs and project actions were given high emphasis, as such, these programs will require thorough literature reviews and examination of readily available practices be undertaken. Such initiatives would include but not limited to the NQF practices especially if there were new high impact actions that target the problems listed in the NQF report. Far more important than attestations of compliance to procedures, policies, and protocols are ongoing programs that have regular measurement and process improvement elements. 5.Sensitivity to use of the word “Problem”: Risk managers at hospital organizations have expressed concern over the use of the word “problem”, therefore wherever possible the term “performance opportunity” was used in the survey in place of the word “problem”. That is not to say the word problem is not used appropriately in the NQF report. It is. What Guiding Principles were used to design the 1.0 Survey Questions? 1.Compliment the NQF Safe Practices Report (May 2003): The survey, weighting system, and ranking system designs are explicitly tied to the problem areas and practices defined by the NQF report. Recognizing the challenges of tying standards, measures, or practices to a report that is written at a snapshot in time, the survey, weighting, and ranking systems take into account that new evidence and refinement of performance improvement methods are being generated all the time. Patient safety is an emerging science and is constantly evolving. The goal is to neutralize the challenges of explicitly tying questions to specific language of practices that are evolving while staying well within the scope of the NQF report.

20 © 2005 TMIT 1.Compliment the NQF Safe Practices Report (May 2003): The survey, weighting system, and ranking system designs are explicitly tied to the problem areas and practices defined by the NQF report. Recognizing the challenges of tying standards, measures, or practices to a report that is written at a snapshot in time, the survey, weighting, and ranking systems take into account that new evidence and refinement of performance improvement methods are being generated all the time. Patient safety is an emerging science and is constantly evolving. Therefore, the guiding principles included focus on the excellent list of safety problems being targeted by NQF practices and apply the “4 A Framework” below. The “4 A Framework” provides real flexibility of interpretation and provides a means of providing partial credit for partial progress and partial credit for commitment to progress. Although the survey will undergo refinement through public review and optimization by our subject matter experts, the design will be kept intact in order to make the survey fair and reasonable. The goal is to neutralize the challenges of explicitly tying questions to specific language of practices that are evolving while staying well within the scope of the NQF report. 2.Partial Credit for Partial Progress: The questions were designed using a “select any that apply” response giving hospitals numerous opportunities for partial credit. Once significant public input is provided, a set of FAQs will be provided for each question to assure that respondents will have clarity regarding what will qualify for credit on a question specific basis. 3.Partial Credit for Commitment: Many of the questions provide partial credit to organizations that make substantial commitment to get started. This will help those that may be “behind the safety curve”. The intent is to provide a clear roadmap to organizations that have heretofore not prioritized safety. These questions are also intended to provide fairness in areas where patient safety issues have not been well publicized. 4.Systematic Application of 4A Framework : The 4A framework recognizes the sequential and interdependent nature of awareness of our performance opportunities, accountability of leadership, the ability to employ practices, and measurable action towards closing performance gaps. This “4A Framework” (updated from a 3 A framework published by C. Denham in 2001) was used as an organizational structure to allow systematic customization of survey questions. Awareness: Clearly, the leaders of an organization must be aware of performance problems before they can make any impact on them. The concept of THE problem or performance opportunity addresses the awareness by hospitals that there is evidence to support a common problem across all hospitals. The concept of OUR problem addresses awareness of the frequency and severity of adverse events to our patient population within our organization and recognition of the impact that practices or performance improvement methods can have on those adverse events. Awareness of THE performance opportunities and OUR performance opportunities are addressed in a relatively standardized manner in each survey question, however they were customized to each problem depending on the current state of awareness in the community. Accountability: A critical success factor to patient safety is accountability of the leadership to performance. Whether the mechanisms of personal performance reviews or performance compensation incentives are used, sustained gains in patient safety frequently do not occur without personal accountability of the leaders. This issue was addressed in a relatively standardized way throughout the survey, however the questions were fine tuned to the scope or care setting addressed by the practice. Ability: An organization may be aware of THE problem – a performance gap common to most hospitals. In fact they may be aware of OUR problem (their own) with clear evidence of frequency and severity of adverse events in their own patient population. They may even have awareness of the impact of a given practice, however if they do not invest in education or skill development and more importantly allocate real protected staff time and dollars to a given problem, the impact on safety is modest at best. Adding a patient safety responsibility to an already overloaded employee without carving out the time and providing them the necessary financial resources to make an impact sends a clear message to the organization. The “ability” related survey questions employ a graduated set of investment levels ranging from investment in education, skill development (training regarding the application of practices or performance improvement methods), dedicated HR, and dedicated line item budget allocations. Actions: Action activities were tied to the NQF cited best practices language as appropriate. Where there have been great strides in best practices, the survey questions provide latitude for activities deserving credit. A set of FAQs will be tied to each survey question that will provide guidance as to what activities may qualify for credit, especially if certain developments in patient safety have been substantiated in the literature after publication of the NQF report. Performance Improvement programs and project actions were given high emphasis, as such, these programs will require thorough literature reviews and examination of readily available practices be undertaken. Such initiatives would include but not limited to the NQF practices especially if there were new high impact actions that target the problems listed in the NQF report. Far more important than attestations of compliance to procedures, policies, and protocols are ongoing programs that have regular measurement and process improvement elements. 5.Sensitivity to use of the word “Problem”: Risk managers at hospital organizations have expressed concern over the use of the word “problem”, therefore wherever possible the term “performance opportunity” was used in the survey in place of the word “problem”. That is not to say the word problem is not used appropriately in the NQF report. It is. What Guiding Principles were used to design the 1.0 Survey Questions? 2.Partial Credit for Partial Progress: The questions were designed using a “select any that apply” response giving hospitals numerous opportunities for partial credit. Once significant public input is provided, a set of FAQs will be provided for each question to assure that respondents will have clarity regarding what will qualify for credit on a question specific basis. 3.Partial Credit for Commitment: Many of the questions provide partial credit to organizations that make substantial commitment to get started. This will help those that may be “behind the safety curve”. The intent is to provide a clear roadmap to organizations that have heretofore not prioritized safety. These questions are also intended to provide fairness in areas where patient safety issues have not been well publicized.

21 © 2005 TMIT 1.Compliment the NQF Safe Practices Report (May 2003): The survey, weighting system, and ranking system designs are explicitly tied to the problem areas and practices defined by the NQF report. Recognizing the challenges of tying standards, measures, or practices to a report that is written at a snapshot in time, the survey, weighting, and ranking systems take into account that new evidence and refinement of performance improvement methods are being generated all the time. Patient safety is an emerging science and is constantly evolving. Therefore, the guiding principles included focus on the excellent list of safety problems being targeted by NQF practices and apply the “4 A Framework” below. The “4 A Framework” provides real flexibility of interpretation and provides a means of providing partial credit for partial progress and partial credit for commitment to progress. Although the survey will undergo refinement through public review and optimization by our subject matter experts, the design will be kept intact in order to make the survey fair and reasonable. The goal is to neutralize the challenges of explicitly tying questions to specific language of practices that are evolving while staying well within the scope of the NQF report. 2.Partial Credit for Partial Progress: The questions were designed using a “select any that apply” response giving hospitals numerous opportunities for partial credit. Once significant public input is provided, a set of FAQs will be provided for each question to assure that respondents will have clarity regarding what will qualify for credit on a question specific basis. 3.Partial Credit for Commitment: Many of the questions provide partial credit to organizations that make substantial commitment to get started. This will help those that may be “behind the safety curve”. The intent is to provide a clear roadmap to organizations that have heretofore not prioritized safety. These questions are also intended to provide fairness in areas where patient safety issues have not been well publicized. 4.Systematic Application of 4A Framework : The 4A framework recognizes the sequential and interdependent nature of awareness of our performance opportunities, accountability of leadership, the ability to employ practices, and measurable action towards closing performance gaps. This “4A Framework” (updated from a 3 A framework published by C. Denham in 2001) was used as an organizational structure to allow systematic customization of survey questions. Awareness: Clearly, the leaders of an organization must be aware of performance problems before they can make any impact on them. The concept of THE problem or performance opportunity addresses the awareness by hospitals that there is evidence to support a common problem across all hospitals. The concept of OUR problem addresses awareness of the frequency and severity of adverse events to our patient population within our organization and recognition of the impact that practices or performance improvement methods can have on those adverse events. Awareness of THE performance opportunities and OUR performance opportunities are addressed in a relatively standardized manner in each survey question, however they were customized to each problem depending on the current state of awareness in the community. Accountability: A critical success factor to patient safety is accountability of the leadership to performance. Whether the mechanisms of personal performance reviews or performance compensation incentives are used, sustained gains in patient safety frequently do not occur without personal accountability of the leaders. This issue was addressed in a relatively standardized way throughout the survey, however the questions were fine tuned to the scope or care setting addressed by the practice. Ability: An organization may be aware of THE problem – a performance gap common to most hospitals. In fact they may be aware of OUR problem (their own) with clear evidence of frequency and severity of adverse events in their own patient population. They may even have awareness of the impact of a given practice, however if they do not invest in education or skill development and more importantly allocate real protected staff time and dollars to a given problem, the impact on safety is modest at best. Adding a patient safety responsibility to an already overloaded employee without carving out the time and providing them the necessary financial resources to make an impact sends a clear message to the organization. The “ability” related survey questions employ a graduated set of investment levels ranging from investment in education, skill development (training regarding the application of practices or performance improvement methods), dedicated HR, and dedicated line item budget allocations. Actions: Action activities were tied to the NQF cited best practices language as appropriate. Where there have been great strides in best practices, the survey questions provide latitude for activities deserving credit. A set of FAQs will be tied to each survey question that will provide guidance as to what activities may qualify for credit, especially if certain developments in patient safety have been substantiated in the literature after publication of the NQF report. Performance Improvement programs and project actions were given high emphasis, as such, these programs will require thorough literature reviews and examination of readily available practices be undertaken. Such initiatives would include but not limited to the NQF practices especially if there were new high impact actions that target the problems listed in the NQF report. Far more important than attestations of compliance to procedures, policies, and protocols are ongoing programs that have regular measurement and process improvement elements. 5.Sensitivity to use of the word “Problem”: Risk managers at hospital organizations have expressed concern over the use of the word “problem”, therefore wherever possible the term “performance opportunity” was used in the survey in place of the word “problem”. That is not to say the word problem is not used appropriately in the NQF report. It is. What Guiding Principles were used to design the 1.0 Survey Questions? 4.Systematic Application of 4 A Framework: The 4A framework recognizes the sequential and interdependent nature of awareness of our performance opportunities, accountability of leadership, the ability to employ practices, and measurable action towards closing performance gaps. This “4A Framework” (updated from a 3 A framework published by C. Denham in 2001) was used as an organizational structure to allow systematic customization of survey questions.

22 © 2005 TMIT ACCOUNTABILITY BOARD CEO SR. EXECs DEPT HEAD Commitment to Report Board Commitment to CEO Accountability Commitment to Exec Accountability Commitment to Dept. Head Accountability The 4 A Framework provides a graduated scale of options for to Awareness, Accountability, Ability, and Action. The survey design was intended to deliver partial credit for partial progress in each of the 4 A categories. Partial credit for commitment is provided not only to help stratify the respondents but to create a Hawthorne effect: to encourage commitment through participation in the survey and recognition that a hospital organization could increase its score by making a commitment at the time of survey response. The Rural Hospital Task Force will apply the 4 A Framework to the first 3 Leapfrog Leaps. The objective is to create a fair and reasonable set of survey questions to address the unique characteristics of rural hospitals. 4 A Framework Confidential – Not to be distributed In Strategic or Ops Plan Measured Events Report to Admin Evidence Of Education Commitment to Educate Commitment To Measure and Report Commit to Strategic/Ops Plan THE GAP OUR GAP AWARENESS Line Item Budget Dedicated HR Invest in Skills Invest in Education Commit to Budget Commit to Dedicated HR Commit to Invest in Skills Commit to Invest in Education ABILITY Enterprise PI Rigorous Practice Clinical Unit Dept. or Svc Line PI Intermediate Level Practice Actions Basic Practice Actions Commit to Enterprise PI or Rigorous Practices Commit to Clinical Unit, Dept. or Svc. Line PI Commit to Invest in Skills Commit to PI ACTION

23 © 2005 TMIT ACCOUNTABILITY BOARD CEO SR. EXECs DEPT HEAD Commitment to Report Board Commitment to CEO Accountability Commitment to Exec Accountability Commitment to Dept. Head Accountability Confidential – Not to be distributed In Strategic or Ops Plan Measured Events Report to Admin Evidence Of Education Commitment to Educate Commitment To Measure and Report Commit to Strategic/Ops Plan THE GAP OUR GAP AWARENESS Line Item Budget Dedicated HR Invest in Skills Invest in Education Commit to Budget Commit to Dedicated HR Commit to Invest in Skills Commit to Invest in Education ABILITY Enterprise PI Rigorous Practice Clinical Unit Dept. or Svc Line PI Intermediate Level Practice Actions Basic Practice Actions Commit to Enterprise PI or Rigorous Practices Commit to Clinical Unit, Dept. or Svc. Line PI Commit to Invest in Skills Commit to PI ACTION In Strategic or Ops Plan Measured Events Report to Admin Evidence Of Education Commitment to Educate Commitment To Measure and Report Commit to Strategic/Ops Plan THE GAP OUR GAP AWARENESS

24 © 2005 TMIT ACCOUNTABILITY BOARD CEO SR. EXECs DEPT HEAD Commitment to Report Board Commitment to CEO Accountability Commitment to Exec Accountability Commitment to Dept. Head Accountability Confidential – Not to be distributed In Strategic or Ops Plan Measured Events Report to Admin Evidence Of Education Commitment to Educate Commitment To Measure and Report Commit to Strategic/Ops Plan THE GAP OUR GAP AWARENESS Line Item Budget Dedicated HR Invest in Skills Invest in Education Commit to Budget Commit to Dedicated HR Commit to Invest in Skills Commit to Invest in Education ABILITY Enterprise PI Rigorous Practice Clinical Unit Dept. or Svc Line PI Intermediate Level Practice Actions Basic Practice Actions Commit to Enterprise PI or Rigorous Practices Commit to Clinical Unit, Dept. or Svc. Line PI Commit to Invest in Skills Commit to PI ACTION ACCOUNTABILITY BOARD CEO SR. EXECs DEPT HEAD Commitment to Report Board Commitment to CEO Accountability Commitment to Exec Accountability Commitment to Dept. Head Accountability

25 © 2005 TMIT ACCOUNTABILITY BOARD CEO SR. EXECs DEPT HEAD Commitment to Report Board Commitment to CEO Accountability Commitment to Exec Accountability Commitment to Dept. Head Accountability Confidential – Not to be distributed In Strategic or Ops Plan Measured Events Report to Admin Evidence Of Education Commitment to Educate Commitment To Measure and Report Commit to Strategic/Ops Plan THE GAP OUR GAP AWARENESS Line Item Budget Dedicated HR Invest in Skills Invest in Education Commit to Budget Commit to Dedicated HR Commit to Invest in Skills Commit to Invest in Education ABILITY Enterprise PI Rigorous Practice Clinical Unit Dept. or Svc Line PI Intermediate Level Practice Actions Basic Practice Actions Commit to Enterprise PI or Rigorous Practices Commit to Clinical Unit, Dept. or Svc. Line PI Commit to Invest in Skills Commit to PI ACTION Line Item Budget Dedicated HR Invest in Skills Invest in Education Commit to Budget Commit to Dedicated HR Commit to Invest in Skills Commit to Invest in Education ABILITY

26 © 2005 TMIT ACCOUNTABILITY BOARD CEO SR. EXECs DEPT HEAD Commitment to Report Board Commitment to CEO Accountability Commitment to Exec Accountability Commitment to Dept. Head Accountability Confidential – Not to be distributed In Strategic or Ops Plan Measured Events Report to Admin Evidence Of Education Commitment to Educate Commitment To Measure and Report Commit to Strategic/Ops Plan THE GAP OUR GAP AWARENESS Line Item Budget Dedicated HR Invest in Skills Invest in Education Commit to Budget Commit to Dedicated HR Commit to Invest in Skills Commit to Invest in Education ABILITY Enterprise PI Rigorous Practice Clinical Unit Dept. or Svc Line PI Intermediate Level Practice Actions Basic Practice Actions Commit to Enterprise PI or Rigorous Practices Commit to Clinical Unit, Dept. or Svc. Line PI Commit to Invest in Skills Commit to PI ACTION Enterprise PI Rigorous Practice Clinical Unit Dept. or Svc Line PI Intermediate Level Practice Actions Basic Practice Actions Commit to Enterprise PI or Rigorous Practices Commit to Clinical Unit, Dept. or Svc. Line PI Commit to Invest in Skills Commit to PI ACTION

32 © 2005 TMIT NQF Survey Preliminary Results Overall number of survey respondents: 1,019 Number of NQF Survey Respondents: 893 NQF Survey Respondent Percentage: 88% 75% Non Profit – 25% For Profit Report to be Published 2 nd Quarter of 2005

33 © 2005 TMIT NQF Survey Preliminary Results 7 in 10 hospitals require a pharmacist to review all medication orders before medication is given to patients 8 in 10 hospitals have implemented procedures to avoid wrong-site surgeries 7 in 10 report they do not have an explicit protocol to ensure adequate nursing staff 7 in 10 do not have policy to check with patients to make sure they understand the risks of their procedures

34 © 2005 TMIT NQF Survey Preliminary Results 6 in 10 lack procedures for preventing malnutrition in patients 5 in 10 report they do not have procedures in place to prevent bed sores (pressure ulcers) 4 in 10 hospitals lack policies requiring workers to wash their hands with disinfectant before and after seeing a patient

40 © 2005 TMIT AssessCollectSubmitPlan Prepare Stage 1: Prepare Obtain hard copy or digital PDF version of the NQF Safe Practices for Better Health Care: A Consensus Report Print a hard copy of the Leapfrog survey and Frequently Asked Questions (FAQs) Organize Survey Submission team

46 © 2005 TMIT AssessCollectSubmit Prepare Stage 2: Plan Pull a team of “internal experts” together to help answer the survey Including: 1.Nursing 2.Pharmacy 3.Infection Control 4.Surgical Services 5.Administration Assign team member responsibilities for individual survey questions Develop Survey Submission Plan Plan

47 © 2005 TMIT AssessSubmit Prepare Stage 3: Collect Each team member collects source documents to support survey question answers Inventory source documents to each Safe Practice; establish a filing system as resource for gap analysis and future survey submissions Perform gap analysis to determine what documents are missing that need to support remaining survey questions Plan Collect

48 © 2005 TMIT Submit Prepare Stage 4: Assess Create a draft survey to determine baseline score Identify pre-submission actions that can be immediately implemented to finalize an answer to any survey questions. Identify Commitment answers to survey questions to optimize survey score Prepare potential Commitment Scenarios (see example) Plan Collect Assess

49 © 2005 TMIT Prepare Stage 5: Submit Final CEO Briefing Review baseline survey score Make decisions regarding immediate pre-submission actions Present optimized score with commitments Give recommendations for Performance Improvement Projects Plan Collect Assess Submit

50 © 2005 TMIT Prepare Stage 5: Submit (Continued) Submit to Leapfrog Web Site: www.leapfrog.medstat.com www.leapfrog.medstat.com Obtain CEO agreement to certify submission Acquire a Security Code from the Leapfrog Web Site Create Follow-up Action Plan Plan Collect Assess Submit

51 © 2005 TMIT “The Hawthorne Effect” Definition: Initial improvement in a process of production caused by the obtrusive observation of that process (1) or in simple English… Individual behaviors may be altered because they know they are being studied (1)Source: Web Dictionary of Cybernetics and Systems

52 © 2005 TMIT “The Hawthorne Effect” We Recommended Submitters Generate 3 Scenarios: 1.Raw Score (with no commitments or immediate actions) 2.Score if Immediate Actions Taken (pre-submission) 3.Score if Commitments Made ( up-score by commitments) We recommended Submitter calculate costs to up score by scenario Our Objective: To have the CEO allocate resources and “go for it”

58 © 2005 TMIT NQFSP Research Test Bed All Invited Early Access to Upcoming Versions No Cost More Information at: www.SafetyLeaders.org Contact: Carol_Ferguson@TMIT1.orgCarol_Ferguson@TMIT1.org Phone: (757) 565-5411

1 © 2005 TMIT The Patient Safety Officer Executive Training Course Charles Denham, M.D Leapfrog NQF Safe Practices Program.

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1 © 2005 TMIT The Patient Safety Officer Executive Training Course Charles Denham, M.D Leapfrog NQF Safe Practices Program.

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