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Regulation, certification and accreditation- Impossible without pressure: the Regional Hospital of Locarno experience

International Congress “Sécurité des patientes - avanti!”Basel, November 30th, 2011

A. Greco, L. Merlini, C. Canonica, R. Monotti, S. Schlunke

Contents

� Introduction� EOC pilot project: JCI accreditation of the

Regional Hospital of Locarno «La Carità»

� First results and lessons learned� Risk for falls management: the «La Carità»

Hospital experience

� JCI and drugs management� Is coertion necessary to achieve a certification?

The surgeon point of view

Introduction


Angela Greco, Luca Merlini


Foreword – A comparison across regulation, certification and accreditation

State of the art and scientific evidence

Technical –Professional

Assessment and Consultation

Scientific Society

Few

Excellent

Prestige

Voluntary

Promotion of quality and patient safety

AccreditationRegulation/Licensure Certification

Goal Selection of Vendors Promotion of quality

Option Mandatory Voluntary

Impact Financial Prestige

Level of Quality Adequate Adequate

Dissemination All Many

Management Region/CantonSeveral certification

organizations

Process Inspection/Assessment Assessment

Contents RegulatoryOrganizational-

managerial

References Regulations Related Standards


“There is no magic formula for organizations engaged in quality management. What works well in a healthcare organization may not work at all in another.Each healthcare organization must create a quality management structure in its own image and likeness.”

reviewed by Berwick D. et al. Can quality management really work in healthcare? Quality Progress1992; 25 (4:25).

Our perspective....


The questions we will try to answer

� Regulation, certification and accreditation: is it possible without pressure?

� External pressure?

� Internal pressure from whom?�Hospital’s managers?�Project managers?�Commitment within the project team?

EOC pilot project: JCI accreditationof the Regional Hospital of Locarno


Luca Merlini, Angela Greco


The strengths of Joint Commission Accreditation

� The Joint Commission was founded almost 60 years ago� It was established by and for the health care industry

� It evaluates the entire hospital as patient care involves complex interactions amongst all of the functions and processes of an organization

� It focuses on systems, rather than on individuals

� It drives ongoing improvement� Standards concern structures, processes, and outcomes

� It allows for comparison across key issues – it is at the forefront in the development of performance and outcome measures for healthcare organizations

� It uses consensus standards for the evaluation, that are continuously updated

� It engages healthcare professionals in defining the standards and in the evaluation process

� It uses the tracer methodology � It has an international division


An integrated model

JCI

Any questions?

Is it clear foreverybody?


What are the contents ? International standards (4th Edition)

Patient-Centered Standards (organizzati sulla base

di quanto viene fatto direttamente o indirettamente „per“ „al“ paziente):

•Access to Care and Continuity of Care (ACC)•Patient and Family Rights (PFR)•Assesment of Patients (AOP)•Care of Patients (COP)•Anesthesia ans Surgical Care (ASC)•Medication Management and Use (MMU)•Patient and Family Education (PFE)

Health Care Organisation Management Standards (sistematizzati sulla base di quanto viene fatto dallastruttura e dai suoi leaders per garantire e mantenere la qualità dellacura attraverso una corretta organizzazione):

•Quality Improvement and Patient Safety (QPS)•Prevention and Control of Infections (PCI)•Governance, Leadership, and Direction (GLD)•Facility Management and Safety (FMS)•Staff Qualifications and Education (SQE)•Management of Communication and Information (MCI)

SQE

MCI

QPS

PCI

GLD

FMS

PFR

PFE

COPACC

AOP

ASCMMU

IPSG

International patient safety goals (IPSG)


JCI AccreditationProcess Time Line


JCI Accredited Hospital in the worldhttp://www.jointcommissioninternational.org/JCI-Accredited-Organizations/

� Austria (1)� Bahamas (1)� Bangladesh (1)� Belgium (1)� Brazil (18)� Chile (2)� China (12)� Colombia (2)� Costa Rica (3)� Czech Republic (4)� Denmark (11)� Ecuador (1)� Egypt (3)� Germany (5)� Greece (1)� India (16)� Indonesia (4)� Irleland (17)� Israel (6)� Italy (14)

� Japan (2)� Jordan (9)� Kuwait (2)� Lebanon (2)� Malaysia (7)� Mexico (8)� Nicaragua (1)� Nigeria (1)� Pakistan (1)� Panama (2)� Philippines (4)� Portugal (4)� Quatar (5)� Russian Federation (1)� Saudi Arabia (35)� Singapore (14)� South Korea (10)� Spain (7)� Switzerland (1)� Taiwan (11)

� Thailand (15)� Turkey (40)� United Arab Emirates (35)� Yemen (1)


Hospital of Locarno main figures

2009 figures

� 610 employees

� 170 bed capacity

� 85 milion costs (in CHF)

� 7’400 admissions� 56’000 day care

� 37’500 outpatients

� 22’600 emergency room visits� 4’400 surgeries

� 7. 5 average hospital days

� 95 % average rate of bedsoccupation


The JCI project steps and timelinesTempo

Fasi e attività

STUDIO PRELIMINARE

Scelta di un modello qualità di riferimento

Assesment iniziale (pre-survey JCI)

CONCETTO DI MASSIMA

Nuovo concetto qualità EOC (ODL ospedale pilota implementazione JCI)

REALIZZAZIONE

Creazione dei circoli qualità

Analisi degli standard

Individuazione dei possibili miglioramenti

Monitoraggio interno sistematico

Implementazione azioni di miglioramento

Pre-survey JCI

Survey finale per accreditamento JCI

ANALISI DI FATTIBILITÀ: PROPOSTA DI UN "MODELLO QUALITÀ EOC"

I° sem.03

II° sem.03

I° sem.04

II° sem.04

I° sem.05

II° sem.05

I° sem.06

II° sem.06

I° sem.07

II° sem.07

I° sem.08

II° sem.08

Gennaio 2004

Marzo 2004

Maggio 2005

Marzo 2008

Maggio 2008

14 teams approx. 60 people involved

70% behaviors 25% documents 5% indicators


Standard

Over 10 years of engagement in continuous quality improvement (1996-2008)

Standard

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Board of Directors

Empowerment team

Culture of values

Departmental

Organization

Iso9001:2000

Iso14001: 1996

1 Quality Team

Hospital Risk Manag.

JCImock

survey

AccredUnited against pain

Qualypoint

First RCA and

FMECA

JCIAccredit

ation

Hospital as a

service provider organizat

ion

Alignment

RU Strategie

s

ITACA Strategy planning

CPI Iso17025: 1999

Unicefrecogn

ition

Painless HospitalProject

DocQ Patient Pathway

s

4 TQ, CRCC,

CIQ, Facility Safety

Committee

UNICEF reaccreditation

Vision MissionValues

Staff Education dept.

Quality and

internal communi

cation dept.

Internal audits

VisionMissionValues

H-Quality

MissionVision

Values (EOC)

Exprixaward

JCIIndicato

rs Projects

IPSGs

Human Resource Managem

ent

Competency

Model

Controlling

EBM Energy 2000

EFQM Worklife

survey

BSC EOC(2005-2008)

EnergoProject

Patient record review

MBO MBOteam

Fourchet-te verte

BSC Hildebrand

Partnership

PRN SwotAnalysis

Health Promoting Hospital Project T

Q


T

Q

ISO

1998

DSS

2000 20062004 2008

EFQMJCI

Why Locarno?

QualityDepartment


Our first report card

Measurable Elements

met; 1198; 98.7%

Measurable Elements

partially met; 15; 1.2%

Measurable Elements not met; 1; 0.1%

103

89

81

91

80

131

28

82

48

74

173

105

93

20

3

4

2

3

1

1

1

1

0% 20% 40% 60% 80% 100%

MCI - Management of Communication and Information

SQE - Staff Qualif ications and Education

FMS - Facility Management and Safety

GLD - Governance, Leadership, and Direction

PCI - Prevention and Control of Infections

QPS - Quality Improvement and Patient Safety

PFE - Patient and Family Educations

MMU - Medication Management and Use

ASC - Anesthesia and Surgical Care

COP - Care of Patients

AOP - Assessment of Patients

PFR - Patient and Family Rights

ACC - Access to Care and Continuity of Care

IPSG - International Patient Safety Goals

Percentage of total measurable elements of each standards cluster

Measurable Elements met

Measurable Elements partiallymetMeasurable Elements not met


2nd report card: employees’ perception

12; 26% 14; 30%

21; 44%

Medical Doctors

Paramedics (nurses, tech-medical, dietitians, etc.)

Administration (management, human resources, hospitality,maintenace etc.)

0

0

0

2

0

0

0

0

0

0

0

0

0

0

21

21

19

13

9

15

30

13

9

13

13

19

17

15

74

74

74

66

85

79

66

81

77

85

77

77

74

83

0% 20% 40% 60% 80% 100%

MCI - Management of Communication and Information

SQE - Staff Qualif ications and Education

FMS - Facility Management and Safety

GLD - Governance, Leadership, and Direction

PCI - Prevention and Control of Infections

QPS - Quality Improvement and Patient Safety

PFE - Patient and Family Educations

MMU - Medication Management and Use

ASC - Anesthesia and Surgical Care

COP - Care of Patients

AOP - Assessment of Patients

PFR - Patient and Family Rights

ACC - Access to Care and Continuity of Care

IPSG - International Patient Safety Goals

Percentage of total answerers (n. 47)

Not usefull

Partially usefull

Usefull


Our strategies to implement the project:

� Clear and precise goals� Work method and clear standards for reference� Third-party authority (JCI) to overcome the institutional self-

regarding nature� Incentive (the will to achieve JCI accreditation)� Choice of charismatic individuals as part of the patient records

review committee� Persistent identification of new areas for improvement� Ongoing staff education� Communication strategy: poster campaign on hospital wards� Reassessment of the evaluation tasks assigned to the various

professionals in order to eliminate redundancies� Adaptation and simplification of patient records� Intensive supervision by senior physicians and head nurses


Some other keys to successEOC Quality Strategic

Committee

EOQUALPDCA Method CQI Philosophy

(Continous QualityImprovement)

QualityCritical area Team

Committee on infrastructure

safety

Committeeon key quality

data

Committeeon Nutrition

Committeeon medical

records review

Committeeon hygiene

RF

RGD

Quality

Facilities and

operations Team

QualityWoman-child Team

QualitySurgery Team

QualityMedicine Team

Hospital Quality and risk management

Commitee+ Quality

Department

QualityCritical area Team

Committee on infrastructure

safety

Committeeon key quality

data

Committeeon Nutrition

Committeeon medical

records review

Committeeon hygiene

RF

RGD

Quality

Facilities and

operations Team

QualityWoman-child Team

QualitySurgery Team

QualityMedicine Team

Hospital Quality and risk management

Commitee+ Quality

Department


JCI project organization chart (3rd Edition of Standards)


Complicated easy vs Simple hard

� self-discipline� generosity� listening� trust

Synergy and communication

“The whole is more thanthe sum of its parts ”

(Aristotle)

JCI

E D

C

B

AH

G

F


Lessons learned (1)

� Resistance to change� Overcome the suspicion about the system benefits� Initial increased workload / commitment� Stress of recent months� The amount of information to be taken into consideration� Training time� The difficulty of being a "pioneer“� Need to review the documentation� Modification of professional conduct


Lessons learned (2)

� Interdisciplinary work� Provide disseminated leadership� Self-analysis and setup of improvement plans� Comparison with others (not self-referent)� Quality suveryors� Matches cantonal requirements� Standard JCI ≈ EOC/TI/CH guidelines� Learning from patients� Manage risks and identify potential damage� Discover hidden waste, dangers and inefficiencies� Efficient resources allocation� Data-based decision making� Superivison of clinical area by the administrator

Fall risk management: the «La Carità»Hospital experience


Chiara Canonica, Angela Greco, Giovanni Rabito


International Patient Safety Goals

6. Reduce the Risk of Patient Harmresulting from Fallsl

How?

Initial assessment for fall riskAOP.1.6 EM 4

Reassessment of patient harm when indicated by a change in condition, medications, etc.

AOP.1.6 EM 5

Implementation of measures to reduce fall risk for those assessed to be at riskAOP.1.6 EM 6

SO WHAT ARE WE DOING?


INITIAL SITUATION

- initial nursing assessment based on experience rather than objective data

- reassessment? - information / education / prevention measures ?

- monitoring ?

- adverse event reporting ?


from single thinking…I know my jobI am experienced

…to critical thinking• definition of a screening tool / literature

• revision of policies / education

• professional integration

Common goalReduce the Risk of patient harm resulting

from falls

IPSG 6 /JCI


If RISK SCORED ≥ 3: 1. Implement fall prevention protocol2. Recommend P.T. consult to MD3. Provide prevention education brochure to family and visitors (with prior consent)

Initial nursing assessment: fall risk assessment (Schmid Fall Risk Assessment Tool)

CURRENT SITUATION

Dimensione Protocollo Punteggio

Età

18 - 75 anni 0

≥ 75 anni 1

Mobilità

Indipendente, deambulazione senza disturbi nell’andatura 0

Deambulazione o trasferimenti con assistenza o ausili 1

Deambulazione con andatura insicura senza assistenza 1

Impossibilitato nella deambulazione o nei trasferimenti 1

Evacuazione

Indipendente 0

Necessita di assistenza per l’evacuazione 1

Incontinente 1

Stato mentale

Vigile e orientato 0

Costantemente confuso 1

Periodicamente confuso 1

Stato sensoriale

Nessun deficit 0

Deficit visivo e uditivo 1

Farmaci

Anticonvulsivi, Benzodiazepine, Antipertensivi, Diuretici, Antipsicotici, Antiparkinsoniani, Psicotropici 1

Nessuno dei precedenti farmaci 0

Punteggio totale


Risk reduction measures: the fall prevention protocol


But …. are all patients being assessed as defined in the policies we have written?

Anamnesi in fermieristica

50

228

122

152

5

30

41

18

25

21 178

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Anno 2007 Anno 2008 Anno 2009 Anno 2010

Mobilizzazione - Screening rischio cadute

Completo Incompleto Assente


...what if a patient falls anyways?


Fall risk analysis using facility and equipment safety checklist

Corrective actions

A. Greco, L. Merlini, C. Canonica, R. Monotti, S. SchlunkeG. Rabito, A. Greco / 05.11.2010 / Pag. 34

- Annual and six-monthly detailed analyses, comparison against goals, EOCbenchmarking

- Staff education and sensitization: once a year presentation about results and corrective actions

Reporting -Corrective actions and communication


Conclusion example PDCA cycle applied to the

patients’ risk for falls

Planning

• Identification of goals and strategiesto reduce the risk of falling (Annual plan for quality and patient safety)

Implementation

•Assessment as part of patient history

•Adoption of preventive measures (I-SAN-014)

• Systematic monitoring of fall events

Check

• The quality indicators committee biannually evaluates the overall trend of results against planned goals

• Patient record review committee four-monthly evaluation

• Falls committee

Action/reaction

• staff education/sensitizazion

• analysis of facility safetyelements in inpatient rooms and bathrooms that may contribute to the fall event

JCI and drugs management


Rita Monotti, Michela Pironi


Drugs management: AIMS

� Many aims to achieve regarding every step of the drug’s process (HIGH RISK PROCESS): 85 standards MMU. For example:

=> safe concentrate electrolytes storage

=> safe drugs samples management=> effective medications labelling after preparation

=> effective method for patient’s identification before

administration

� Many changes necessary to increase patient’s security and be compliant to JCI standards

One of them:

INCREASE THE SECURITY in DRUGS PRESCRIPTION

according to JCI requirements


Drugs prescription &

Detailed JCI requirements:

1. ABOUT COMPLETE PRESCRIPTIONS

(date, time, drug’s name, dose, frequency, route of administration,

doctor’s signature, details for “as required” drugs)

2. ABOUT DRUGS PRESCRIPTION MODIFICATIONS

3. ABOUT THE DOUBLE CHECK OF EVERY NEW DRUG PRESCRIBED

(allergy? interactions? drug appropriate? Drug necessary? Is the best

dose, frequency, route of administration for the patient?...)


Initial situation at Locarno Hospital- many prescription papers

- transcription on nurse’s documents

NEED for a cultural change!


First step Written policy about drugs prescription

requirements

1. Definition of which elements are necessary to prescribe properly

2. Definition of which elements need to be controlled during the double check

… but many doctors objections, especially about the prescriptions“double check”

(“who will do it?” “No time do it” “Is it necessary? “Senior doctor double checked by a junior doctor?”)


Some data from the literature

40%41%

20%23%

- ORDERING: 39%

- TRANSCRIPTION: 56%

Significant clinical consequence

Serious/ fatalclinical

consequence

Drugs related errors:63/133 (47%) patients : drugs’ related problems

Errors in the medication process: frequency, type and potential clnicalconsequencesM. Lisby et al Int.J. ofQuality in Health Care 2005; Vol 17, N 1:15-22

� prescription errors: 37%� transcription errors: 53%

Drugs related errors: 65/165 patients

(1934 prescribed agents)

High incidence of medicationdocumentation errors in aSwiss university hospital due to the handwrittenprescription processHartel et al, BMC Health Services Research2011 Aug. 18 11 :199


Second stepCreation of a “guided ” prescription paper

Implementation: difficult! Compliance to improve


Third stepCheck & improve the compliance

1. Pocket guide about drugs prescription & double check requirements distributed among Doctors (Compromise: self control admitted !)

2. Audits, tracers & monitoring of clinical records (to test completeness)

3. Qualypoint promotion (spontaneous notification

of ADEs & drugs related errors to the quality service) => Analysis to prevent new errors


Medical records general completeness


Drugs related problems analysis

� 145 ADE/drugs related problems spontaneously notified in 15

months (2007-2008)

� 4.8% led to a specific patient’s treatment!

“Survey and management of non conformities drugs related”, M.Pironi, A.Greco, D.Caronzolo, B. Waldispuehl - Poster GSASA

Non conformities related to drugs prescription, transcription, administration (2007-2008)

43%

18%

23%

16% Transcription errors

Not written medical orders

Incomplete drugsprescription

Drugs prescribed in allergicpatients


Current situation at Locarno Hospital

� Prescription done on a “white paper”

� Many different prescriptions papers� Transcription in a nurse document, used for drugs administration

� No double check of new drugs prescribed

� Some prescriptions done in a “guided paper” ; well defined prescriptions requirements, but different prescriptions papers still used

� More sensitivity to spontaneously report ADE or drugs related errors & more sensitivity for new drugs prescription double check

� Transcription still present (no “drug chart” implemented)� Preparation process improvement

Future: Informatic prescription

Test of a “drug chart” (shared document Dr/nurses) to reduce transcriptions and decrease the number of prescription papers(implemented only for Intensive care)


Conclusion

� JCI: input to review the drugs related processand increase its security; it requires of a big cultural change (energy & time consuming)

For that reason necessity to have:- clear objectives- CLARITY; COHERENCE & COHESION AMONG MEDICAL ANDNON MEDICAL LEADERSHIP TO CREATE AN INTERNALPRESSURE- Lobbying pressure by Pharmacists missing

Is coertion necessary to achievea certification? The surgeon pointof view


Stéphane Schlunke


Certification & Coertion

My objective:share the experience ofcertification in the eyes of a(egocentric) surgeon


Coertion & Certification


Coertion No

�Evidence of higher quality bycertification

�Seek of evidence drives doctors dailywork

�Doctors are smart and passion drivenworkers


Coertion Yes

�Doctors are human... who fear changesand loss of «power»

�Doctors are «free» thinkers... controlsteps down their «independance»

� I’m a doctor! I know what I’m doing!


Certification & Fear

� Fear brings automaticreactions... from the Ego

� Automatism... «this is the way we do it... we always did it thatway»

� Automatism...resistance to the unknown


EGO & Surgeons

�How can you consciously inflict a wound to another human being if youare not sure that YOU are right? thatyou excactly know what you are doing?

�As a matter of fact there is still littleevidence in surgery... surgery remaineda kind of «art»


Surgeons are artist’s

�The talent of improvisation is of greathelp for a surgeon (and his patient) during difficult and rarely seen clinicalsituations

�Controlling as from measurements(certification) are likely to cut the «wing’s of inspiration»...



� WAY OUT:�there is a noble goal in certification�if you really measure (certify) what you are

doing... then you really know what you are doing!�more control = more quality and patient safety


[email protected]; [email protected]; [email protected]; [email protected];

[email protected]

Thank you!

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