Chapter 7:

Management and Communication

Prepared by:

APIC DFW Professional Advancement Committee

Chapter 7

Pre-Study Session Quiz

1. Which of the following terms refers to patient harm that is the result of treatment by the healthcare system rather than the health condition of the patient?

a. Adverse event

b. Dire consequence

c. Unanticipated event

d. Sentinel event

2. Obstacles for building a culture of patient safety in healthcare include all of the following except:

a. Assignment of blame on healthcare providers

b. High staff turnover rates

c. Lack of resources for needed change

d. Placement of accountability on healthcare systems

3. When an error does not result in an adverse event for a patient because the error was caught, it is called a(n)_____

a. Missed event

b. Near-miss event

c. Error report

d. No-harm event

Affiliated Resources for Study

(13 questions)

• APIC Text Chapters 1-6, 8, 9, 16, 17, 18

• Ready Reference for Microbes

• Control of Communicable Diseases Manual

• The Infection Preventionists’ Guide to the Lab

•

General Information

• Fundamental to the practice of IP & C

• Includes these 3 core concepts

1. Planning

2. Communication & feedback

3. Quality (Performance Improvement) & Safety

•

Strategic Plan

Per The Joint Commission (TJC), a comprehensive infection prevention and control program must have a detailed strategic plan that:• Prioritizes the identified risks for acquiring and transmitting infections.• Sets goals that include limiting (a) unprotected exposure to pathogens; (b) the

transmission of infections associated with procedure; and (c) the transmission of infections associated with the use of medical equipment, devices, and supplies.

• Describes activities, including surveillance, to minimize, reduce, or eliminate the risk of infection.

• Describes the process to evaluate efficacy of the plan.

•

Planning

• Important to establish a mission & vision for the IP&C Dept• Evaluate/update (if needed) annually • Annual risk assessment is essential (& mandatory) to monitor the state of

the dept• Annual program assessment: summarizes & evaluates current year’s

program • Annual plan for the next year is then developed based on risk assessment

& program assessment; goals are established & plan to attain created.

Usually the 1st thing surveyors request when evaluating IP programs

•

THE PLAN

• Components

• “The plan” initially began many years ago to serve only as basis for the

next year’s infection surveillance priorities

• Now more complex

• HAI goals

• Construction program,

• Environment of Care

• Employee Health,

• Education, etc.

•

Additional Planning Activities

• Based on needs assessment, IP need to consider additional practices & products which could enhance infection prevention

• Evaluation of practices/products are based on evidence available, feasibility, cost analysis, etc.

• Business modeling, cost/benefit analysis are other terms used for this process

•

Communication & Feedback

• What:• data/reports, policies/procedures/recommendations for improvement,

sentinel event identification/review, reports of possible HAIs attributable to previous facilities, reports of communicable diseases to receiving entities upon transfer

• When:• internally--data/reports need to be shared regularly & frequently with all

stakeholders (leadership, staff, physicians, etc.); • externally--reportable diseases to appropriate agencies & data to NHSN &

other federal entities within timeframes as mandated

•

Communication & Feedback

• Why:• Important to report data internally to keep stakeholders informed on facility

HAI status & also need to discuss improvement opportunities/ implementation plans & status frequently to support projects as needed;

• Most externally reported data reported due to requirement by state/federal entity

•

Communication & Feedback

• How: reporting may be done verbally, via paper, phone, fax or electronic means; every effort is made to maintain confidentiality

• Effective communication techniques are vital to the success of IP programs! • It’s not just what you say, but HOW you say it

• Be approachable (body language)

• Be an active listener

• Be collaborative/facilitative

• Put a smile in your voice (as much as possible)

Quality, Performance Improvement, and Safety

• The landmark IOM reports:

• To Err is Human: Building a Safer Health System

• Crossing the Quality Chasm: A New Health System for the 21st Century

• Presented shocking statistics regarding healthcare errors & their resulting patient morbidity & mortality, & most importantly, brought patient safety to the forefront.

•

Quality, Performance Improvement, and Safety

• To Err is Human presented six aims of patient care: safety, effectiveness of care,

timeliness, efficiency & equity; IP&C programs encompass all of these goals &

deal with many broad quality issues such as policy & procedure development

(to enhance organizational consistency), staff education (communication),

community outbreaks and environmental cleanliness, to name a few

• The passion for the highest quality & safest care is what drives the IP to do

more, to do it better, to never give up; the key is to instill/infuse this drive for

excellence throughout the facility, creating a culture of quality & safety, which

guides every healthcare intervention every time

•

Quality, PI, and Safety, cont.

•

Quality & Safety: Tools to Use

• Performance Improvement teams a. Multidisciplinary teams: valuable in helping to instill a quality-focused culture orprocess; align efforts with the mission, vision & values of the dept. & organizationb. Project teams: largely composed of subject matter experts (mostly frontline staff) who do the work, creative & innovative thinking encouraged to solve problems c. Guidance teams: responsible for oversight of certain aspects of the program; morestructured than PI & project teams; example would be hand hygiene oversight teamd. Interdisciplinary teams: establish group norms & logistical issues, such as meeting places & times, assignments & time frames e. Team charters help ground all teams by establishing team mission f. Support of senior leadership/management is essential for teams to be effective & accomplish goals; a quality culture supported by leadership enhances the success of all PI teams

•

• Gap analysis: method to compare current practices with best practices & to

identify steps to take to move from point A to point B; table format generally used

which list the goal being considered, the evidence for improvement (such as TJC

standard), & whether compliant with the topic or not compliant, & the actions

needed to become compliant

• Root cause analysis (RCA): looks at the what & why of major events, sentinel

events &/or errors; goal is not to place blame, but rather to identify human factors

which could have contributed to the issue & redesign to create a safer system; team

includes frontline staff & individuals most familiar with the incident who have

capability to dig deeper into incident

Tools-methods of analysis

•

• Fishbone diagrams: often used with RCAs, but can be used for anysafety/quality projects which are multifactorial; compartments of areas identifiedare listed as major categories (big bones) with related issues listed as small boneson the big bones -- can become quite complex

Cause(s) Effect (Problem)

Tools-methods of analysis

•

Tools-methods of analysis, cont.

• Failure Mode Effect Analysis (FMEA): preventive, proactive approach to identify

potential failures & chance of failure; basically a multidisciplinary team of

process/content experts brainstorming to identify problems with proposed processes

& using a Likert scale to assign severity & probability of occurrence; team rates the

severity & likelihood of adverse events

• SWOT analysis= Strengths, Weaknesses, Opportunities & Threats; categories are

placed in a square table & appropriate items listed under each category; frequently

used in healthcare to improve outcomes, develop strategic vision/plans or investigate

public health issues; shows what the organization should plan for & guide efforts

within a formal framework

•

Tools-methods of analysis, cont.

• Multivoting: it is what its name implies; members of group vote until a list is narrowed

down & prioritized; might be used to choose annual PI projects for a quality dept, for

example

• Goal-directed checklists: enhance patient safety/quality of care by following very

prescriptive checklists (CL insertion bundle); IHI (Institute of Healthcare

Improvement) was the major driver for checklists/bundles in HC; monitoring for

compliance with checklists/bundles is another tool to use

•

Other Quality Tools & Terms

• Tools & methods to determine variation in processes

• Important to monitor & control variation within a process

• Basically, consistent & predictable processes without variation are easier to improve

than erratic processes

• Very complex topic; need to study APIC Text Chapter 14 & be familiar with

Statistical Process Control, as you may see some of the terms on the exam (such as

affinity diagrams & pareto charts)

•

Other Quality Tools & Terms

• Six Sigma & the Lean Approach

• Six Sigma concentrates on precision & accuracy which leads to defect-free

products or services;

• Started in the manufacturing sector (Toyota & Motorola)

• Lean methods: strategies such as value-stream mapping, transactional

mapping & just-in-time training

• Both use a DMAIC format (Define, Measure, Analyze, Improve & Control);

creates a data-driven quality strategy for improving processes

•

Other Quality Tools & Terms, cont.

• PDC/SA (Plan, Do, Study or Check, Act)

• Enforces the concept that improvement & change are cyclical & continual activities

• TJC expects to see this Quality Improvement methodology present in IP&C programs

• Plan: identifying resources, risks, goals & activities to achieve goals (usually to reduce the risk of HAI for IP&C)

• Do: Strategies identified in planning phase are implemented

• Study/Check: Asks the question “Did it work?”; involves data evaluation & presentation to check if goals for HAI reduction met & to share the outcomes; if goals not met, identify barriers

• Act: implement plan for improvement

•

Performance Measurement

• Important to measure BOTH processes & outcomes

• The who, what, when, where & how of performance measurement are in a

constant flux, but choosing appropriate measures is of vast importance to get the

info. needed to determine if improvement needed (or not)

• Study Chap. 17 of the APIC text—too much detail to go into with this course, but

to be prepared for the CIC exam, it is highly recommended to study this chapter in

depth.

•

Medical Errors

AHRQ (Agency for Healthcare Research & Quality) summarizes the causes of medicalerror to be related to:

A.Communication problems

B. Inadequate information flow

C. Human problems

D.Patient-related issues

E.Organizational transfer of knowledge

F. Technical failures

G.Inadequate policies & procedures

•

5 Attributes of a Safety Culture

Five attributes of a safety culture (as outlined by the National Patient SafetyFoundation)

1. All workers, including frontline staff, physicians & admin.) accept responsibility forthe safety of themselves, their coworkers, patients & visitors

2. Safety has priority over financial & operational goals

3. The organization encourages & rewards the identification, communication &

resolution of safety issues

4. There are provisions for organizational learning from incidents

5. The organization allocates appropriate resources, structure & accountability tomaintain effective safety systems

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Sentinel Events

• Sentinel events: defined by TJC as unexpected occurrences involving death or

serious physical or psychological injury, “or the risk thereof ”; serious injury

specifically includes loss of limb or function (such as a joint replacement SSI that

requires removal of the implanted joint). A root-cause analysis (RCA) & action plan

should be performed on these serious events (with thorough documentation) within

45 calendar days of facility’s event awareness; however, reporting sentinel events to

TJC is now voluntary, but strongly encouraged (most facilities complete the RCA &

action plan, but only report “extreme” situations, such as suicide of patient at the

HCF)

•

Adverse Event

• medication and transfusion errors,

• infections,

• complications of surgery (including wrong-

site surgery),

• suicide,

• restraint-related injuries,

• falls,

• burns,

• pressure ulcers,

• misidentification, and

• wrong diagnosis or treatment.

• Patient harm that is the result of treatment by the healthcare system rather than the

health condition of the patient.

• The most common adverse errors affecting patients include:

•

Near-Miss Event

• medication or transfusion reactions,

• communication or consent issues,

• wrong patient or procedures,

• communication breakdown or technology malfunctions.

• An event that was prevented from reaching the patient by either chance or timely

intervention.

• Did not result in injury, illness, or damage - but had the potential to do so.

•

Human Factors and Patient Safety

Limitations that contribute to errors

1. Limited memory capacity; 5-7 pieces of info. are typical for short-term memory

2. Negative effects of stress & associated cognitive tunnel vision used to compensate

& focus in highly intense situations

3. Negative influence of fatigue & sensory overload

4. Overdependence on multitasking skills of staff in complex work environments

•

Patient Safety (cont.)

Risk & Incident Reporting

1. To reduce harm, the how & why of adverse event occurrence needs to be

researched & reported to organizations which collect, aggregate & trend such data

2. Safety event reporting must be a priority (goes along with safety culture)

3. The effectiveness of a patient safety program can partially be measured by increased

*near-miss reporting & HCP openly admitting to mistakes & identifying “broken”

systems before they cause harm

*events in which the unwanted consequences were prevented because there was recovery by planned or unplanned

identification & correction of the failure

•

National Patient Safety Goals (NPSGs)

Established by TJC in 2002

1. National standards for HCFs to adopt in order to improve the most common types of

medical errors

2. In 2004, TJC included IP&C processes in the NPSGs: Goal 7

• Created to address HCP education & compliance with hand hygiene & sentinel

events RCAs & reporting

• In 2009, NPSG expanded to include education regarding MDROs & pt/family

engagement in pt. safety related to HAIs & also requires implementation of

evidence-based practices to prevent device & procedure-associated HAIs

•

AHRQ Recommendations

AHRQ recommends that HCFs focus on the following IP&C initiatives

1. Utilizing barrier precautions to prevent transmission of infection

2. Prudent antibiotic use to reduce C. diff. & VRE

3. Prevention of CAUTI

4. Prevention of CLABSI

5. Prevention of VAP

6. Prevention of SSIs

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The Role of the IP in Patient Safety

1. Reality check: HAIs ARE THE 4th LEADING CAUSE OF DEATH IN THE U.S. (after heart disease,

cancer & stroke) & SSIs are the number two adverse event experienced by hospitalized patients!!

2. Surveillance, prevention & control measures are the FOUNDATION of any program whose aim is to

eliminate harm & injury; these fundamental sills & core competencies are what IPs bring to pt. safety

programs

3. APIC’s Competency Model acknowledges that professional attributes such as teamwork, reasoning, values

& communication as equivalent to the traditional IP skills of knowledge & technical proficiency; these

practice & behavioral standards should be included in the position description & performance appraisal of

every IP, since they demonstrate the valuable assets brought to organizations’ safety programs.

***This program contains just a sampling of the tremendous amount of info. available addressing the IP & Patient Safety:

STUDY Chapter 18 of the APIC text!!!***

Chapter 7

Post-Study Session Quiz

1. Which of the following terms refers to patient harm that is the result of treatment by the healthcare system rather than the health condition of the patient?

a. Adverse event

b. Dire consequence

c. Unanticipated event

d. Sentinel event

1. Which of the following terms refers to patient harm that is the result of treatment by the healthcare system rather than the health condition of the patient?

a. Adverse event

b. Dire consequence

c. Unanticipated event

d. Sentinel event

2. Obstacles for building a culture of patient safety in healthcare include all of the following except:

a. Assignment of blame on healthcare providers

b. High staff turnover rates

c. Lack of resources for needed change

d. Placement of accountability on healthcare systems

2. Obstacles for building a culture of patient safety in healthcare include all of the following except:

a. Assignment of blame on healthcare providers

b. High staff turnover rates

c. Lack of resources for needed change

d. Placement of accountability on healthcare systems

3. When an error does not result in an adverse event for a patient because the error was caught, it is called a(n)_____

a. Missed event

b. Near-miss event

c. Error report

d. No-harm event

3. When an error does not result in an adverse event for a patient because the error was caught, it is called a(n)_____

a. Missed event

b. Near-miss event

c. Error report

d. No-harm event