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Patient-Safety-Final.pptx
- 2. Learning objectives 1. Describe the role of infection prevention and control (IPC) in patient safety programmes. 2. List at least eight main elements of patient safety culture. 3. For each element of patient safety culture, give at least one practical strategy for the IPC professional. 2 December 1, 2013
- 3. Time involved • 45 minutes 3 December 1, 2013
- 4. Introduction • Early pioneers in infection prevention and control (IPC) promoted safe patient care through their work • The World Health Organization Assembly voted in 2004 to create a World Alliance for Patient Safety to coordinate, spread, and accelerate improvements in patient safety worldwide 4 December 1, 2013
- 5. Why is there a patient safety problem in health care? • Complexity of human illness and frailties of human behaviour may result in errors or adverse events • Healthcare associated infections (HAI) may occur from: • Commission (doing something wrong that leads to infection), e.g., not providing timely preoperative antibiotics for appropriate patients, OR FROM • Omission (failure to do something right,) e.g., using poor aseptic technique when inserting a catheter 5 December 1, 2013
- 6. A Culture of Patient Safety - 1 Culture has been defined as the deeply rooted assumptions, values, and norms of an organisation that guide the interactions of the members through attitudes, customs, and behaviours 6 December 1, 2013
- 7. A Culture of Patient Safety Outcomes 7 December 1, 2013
- 8. A Culture of Patient Safety - 2 • Involves: • Leadership • Teamwork and collaboration • Evidence-based practices • Effective communication • Learning • Measurement • A just culture • Systems-thinking • Human factors • Improvement philosophy 8 December 1, 2013
- 9. Leadership - 1 • Senior leaders are responsible for establishing safety as an organisational priority • Leaders set the tone by: • naming safety as a priority • supporting approved behaviours, and • motivating staff to achieve the safest care 9 December 1, 2013
- 10. Leadership - 2 • Strategies for IPC professionals 1. Engage leaders throughout the organisation in support of IPC; assist them in increasing the visibility and importance of infection prevention 2. Seek commitment from senior executives, boards of governance, clinical and support department leaders, and key staff to IPC principles and practices 3. Present a compelling case to leaders that emphasises the decreased morbidity, mortality, and cost when infections are avoided 4. Provide leaders with valid information to help them make decisions about infection prevention 10 December 1, 2013
- 11. Teamwork and Collaboration - 1 • Combine the talents and skills of each member of a team • Serves as a checks and balance method • Strong collaboration and teamwork help minimise adverse events. 11 December 1, 2013
- 12. Teamwork and Collaboration - 2 • Strategies for IPC professionals 1. Foster collaboration and teamwork by engaging staff as partners in developing IPC policies and procedures 2. Encourage a multidisciplinary approach to IPC 3. Participate with teams of caregivers to address infection prevention issues 4. Maintain open communication about infection prevention to include staff and leaders across the organisation 12 December 1, 2013
- 13. Effective Communication - 1 • Open communication encourages the sharing of patient, technological, and environmental information • Communication strategies include use of written, verbal, or electronic methods • for staff education, for sharing IPC data from surveillance, new policies, procedures, and literature studies • Communication should include a reporting system that allows staff to raise practice concerns or errors in care without fear of retribution 13 December 1, 2013
- 14. Effective Communication - 2 • Strategies for IPC professionals 1. Make routine rounds and discuss patients with infections or those at risk of infection with the direct care providers and listen to staff concerns 2. Share surveillance data and new information 3. Develop a secure system for staff to report infection risks 14 December 1, 2013
- 15. Evidence-based Practices - 1 • Use of evidence-based strategies is a basic element of patient safety • This means translating science into practice and standardising practices to achieve the best outcomes • Adoption of best practices often mean changing practice • Changing practice often meets with resistance 15 December 1, 2013
- 16. Evidence-based Practices - 2 • Strategies for IPC professionals 1. Learn about the incentives and barriers to adopting and implementing preferred practices in the organisation 2. Address incentives and barriers in the planning of new and existing policies and procedures for infection prevention 16 December 1, 2013
- 17. Organisational Learning - 1 • Support members so they can • learn together • improve their ability to create desired results • embrace new ways of thinking • transform their environment for better care 17 December 1, 2013
- 18. Organisational Learning - 2 • Strategies for IPC professionals 1. Share infection information with all staff 2. Encourage staff to participate in formulating policies and procedures to reduce infection risk 3. Use adult learning principles to educate staff 18 December 1, 2013
- 19. Measuring Care: Processes and Outcomes - 1 • IPC staff must collect and report reliable data • To monitor compliance with patient care practices • To identify gaps in care • To understand adverse events experienced by patients 19 December 1, 2013
- 20. Measuring Care: Processes and Outcomes - 2 • Strategies for IPC Professionals 1. Emphasise the importance of analysing and reporting infections to staff and leaders 2. Educate staff about their role for reporting infections in order to identify gaps in care that can be corrected 3. Be clear about the purpose and use for data that are collected. This involves precise definitions of colonisation vs. infection, consistent data collection processes, accurate capture of data, and validation of infection rates 4. Stratify data whenever possible for more precise analysis, for example, surgical site infections and infections in the new- born population 5. Determine when to maintain or to eliminate surveillance so that measurement is focused and useful 20 December 1, 2013
- 21. “Systems” Thinking - 1 • Virtually all processes in health care organisations are systems which contain interconnected components, including people, processes, equipment, the environment, and information 21 December 1, 2013
- 22. “Systems” Thinking - 2 • Strategies for IPC professionals 1. Consider the entire system, i.e., how the individual parts interact and how the system should work, when designing even simple IPC processes 2. Ensure that the system provides for supplies, that staff can successfully perform the assigned task(s), that the infrastructure supports the desired behaviours, and that coordinating departments support the infection prevention process 3. Work with others to design a system to achieve and sustain success 22 December 1, 2013
- 23. Human Factors Theory - 1 • How to enhance performance by examining the interface between human behaviour and the elements of a work process (equipment and the work environment) • The design of a care process, such as an operation or cleaning a wound, can benefit from using human factors engineering to reduce infection risk 23 December 1, 2013
- 24. Selected Human Factors Principles Simplify the process: minimise steps and make the process logical and easy to perform, such as having all supplies readily available. Standardise the process: standardise equipment and processes, e.g., standardising care of intravascular catheters to prevent bloodstream infections. Reduce dependence on memory: provide clear written direction, cues, visual aids, and reminders, for items such as preoperative preparation, hand hygiene, isolation precautions, or removal of indwelling devices. Use forcing functions: make it difficult to do it wrong by using equipment like safety needles and needle disposal devices. Work toward reliability: performing a task correctly and consistently, focusing on how to avoid failure, for example, using aseptic technique to insert a Foley catheter into the bladder. 24 December 1, 2013
- 25. Human Factors Theory - 2 • Strategies for IPC professionals 1. Integrate human factors engineering principles, such as standardisation, into patient care practices to promote success in reducing infection risk to patients or staff 2. Anticipate potential process failures in IPC strategies and incorporate methods to prevent them 1. Such as visual cues for staff of expected behaviours (i.e., posters and checklists for surgical preparation) or supplies such as safety needles 3. Ensure that individuals performing the work are competent, there is clarity about the task being performed, that the tools and technologies involved work properly, and the environment supports the care process 25 December 1, 2013
- 26. No Blame – “Just” Culture - 1 • When potentially harmful events such as HAIs occur, an organisation can either review the systems of care and learn from the errors, or blame personnel for making them • In a “just” culture (a key component of a patient safe environment) errors are addressed by providing feedback and encouraging productive conversations, and insisting on unbiased, critical analysis to prevent future errors 26 December 1, 2013
- 27. No Blame – “Just” Culture - 2 • Strategies for IPC professionals 1. Help maintain a “just”, no blame culture by continually focusing on evidence-based practices, epidemiology, and systems rather than “blaming” individuals 2. Use critical thinking to identify and analyse the causes of errors leading to infections so they can be prevented in the future 27 December 1, 2013
- 28. Improvement Philosophy - 1 • To minimise infections (or errors), leaders must not tolerate non-adherence to proven prevention measures • When “best practices” are known, these should be expected of all staff 28 December 1, 2013
- 29. Improvement Philosophy - 2 • Strategies for IPC professionals 1. Monitor evidence-based practices for infection prevention, e.g., isolation/precautions procedures, hand hygiene, sterile technique, and cleaning, disinfection and sterilisation 2. Work to improve “broken” or dysfunctional processes of care and defective systems • Such as lack of soap and water or alcohol gel for hand hygiene, personal protective equipment for staff safety, or appropriate ventilation systems 3. Stay up-to-date on evidence-based guidelines and integrate them into the infection prevention program 4. Focus less on simply achieving “benchmarks” for infections and work continually toward zero infections 5. Do not accept the “status quo” as a long term goal; continually strive to reduce infection rates 29 December 1, 2013
- 30. Examples - 1 Patient Safety Issue Infection Prevention and Control Example Potential Solutions Multiple transfers or patient “hand offs” between staff and services A patient who is admitted and prepared for surgery is transferred or “handed off” from the admission unit to the nursing staff, the operating theatre staff, post anaesthesia staff, and back to the nursing unit. Inadequate skin preparation, lack of timely administration of prophylactic antibiotics, or poor care of the surgical wound may occur. Education about each phase of the surgical process Clear communication strategies Monitoring of competence Reminders, checklists, visual cues Documentation and analysis of preoperative and postoperative processes of care with feedback to staff Multiple types of equipment used for patient care Patients in intensive care, haemodialysis, and other high intensity units often have multiple “lines”, fluids, ventilators, dialysers, and other equipment that must all be managed to avoid infection risks. Indwelling urinary or intravascular catheters and ventilators should be removed when no longer needed. Utilities such as water and air can present a risk if malfunctioning. Education and training of staff on use of equipment Competency assessment before performing work Human factors engineering Equipment maintenance Environmental assessments 30 December 1, 2013
- 31. Examples - 2 Patient Safety Issue Infection Prevention and Control Example Potential Solutions High-risk illness Patients with immunosuppressive diseases, burns, trauma, and high-risk conditions related to age (neonates) are prone to infections. They must be carefully assessed and monitored to prevent infections. Staff education: observation and reporting criteria Population-specific criteria Clear policies and procedures Careful documentation, monitoring, and feedback to staff about infections Time pressure High intensity environments commonly have large workloads and limited time to complete essential infection prevention tasks. For example, nurses often indicate that they are “too busy” to wash hands or perform hand hygiene when appropriate. Time management support; evaluation of workload; staffing and assignments Work environment design, such as (for hand hygiene) availability and location of water, sink design and location, alcohol-based solutions to decrease hand hygiene time 31 December 1, 2013
- 32. Examples - 3 Patient Safety Issue Infection Prevention and Control Example Potential Solutions High-risk procedures/medications Patients are at increased risk of unsafe care and infection during some procedures and with some medications. For example, the lack of preoperative antibiotics at the correct time and with the correct dose or discontinuation at the recommended time can fail to reduce risk of surgical site infections. Develop clear protocols and processes for administration of preoperative antibiotics Educate staff about the procedures Assign responsibilities Monitor compliance with processes and report outcomes Initiate performance improvement when appropriate Distractions and multitasking Distractions during delivery of care or attempting to perform many tasks simultaneously can lead to errors. Staff may omit hand hygiene because of distractions during busy times. Staff using aseptic or sterile techniques may contaminate the area because of distractions. Provide work environment with few distractions Initiate culture of quiet and lack of interruption Encourage one task at a time Include staff in making decisions about work flow and environment Provide cues to remind staff of steps in an activity 32 December 1, 2013
- 33. Examples - 4 Patient Safety Issue Infection Prevention and Control Example Potential Solutions Inexperienced or incompetent care givers: Inexperience or lack of competence in healthcare personnel may lead to bad practice. For example, personnel who insert intravascular catheters and do not feel competent to use the recommended sites, such as the subclavian vein, may choose the femoral vein for insertion with its associated higher infection risk. Analyse why staff feel inexperienced Provide orientation / training for all staff who insert intravascular catheters, including rationale and supervised practice until competency is established Periodically monitor skills and provide feedback 33 December 1, 2013
- 34. Key Points • Safe patient care, including infection prevention, is a priority in all health care settings • A patient safety culture guides the attitudes, norms and behaviours of individuals and organisations • In a safe culture of care, all staff and leaders assume responsibility for the well-being of patients • Patient safety requires teamwork and collaboration, communication, measurement, and techniques such as human factors engineering, systems thinking, no blame - just culture and improvement philosophy 34 December 1, 2013
- 35. References 1. Thompson MA. Patient Safety. In: APIC Text of Infection Control and Epidemiology. 3rd edition. Association of Professionals in Infection Control and Epidemiology, Washington DC.2009; Chapter 12; 12-7-8. 2. Grol R, Berwick DM, Wensing M. On the trail of quality and safety in healthcare. BMJ 2008; 336(7635):74-6. 3. Murphy D. Understanding the Business Case for Infection Prevention and Control. http://www.vhqc.org/files/091020BusinessCaseForIPC.pdf 4. A human factor engineering paradigm for patient safety: designing to support the performance of healthcare professionals. Qual Sat Health Care 2006; 15 (Suppl1):i59- i65.doi:10.1136/qshc.2005.015974 or http://ncbi.nlm.nih.gov/pmc/articles/PMC2464866 5. Donaldson LJ, Fletcher MG. The WHO World Alliance for patient safety: towards the years of living less dangerously. Med 2006; 184(10 Suppl):S69-72. 35 December 1, 2013
- 36. Quiz 1. Patient safety problems may be due to doing something wrong or failure to do what is correct. T/F? 2. A culture of patient safety includes a) Surveillance b) Standardisation c) Root cause analysis d) All of the above 3. Communication should always be verbal. T/F? 36 December 1, 2013
- 37. International Federation of Infection Control • IFIC’s mission is to facilitate international networking in order to improve the prevention and control of healthcare associated infections worldwide. It is an umbrella organisation of societies and associations of healthcare professionals in infection control and related fields across the globe . • The goal of IFIC is to minimise the risk of infection within healthcare settings through development of a network of infection control organisations for communication, consensus building, education and sharing expertise. • For more information go to http://theific.org/ December 1, 2013 37
Editor's Notes
- The EU Council Recommendation on Patient Safety includes the prevention and control of healthcare associated infections. It was issued in June 2009. It includes definitions of the terms “patient safety”, “adverse event” and “harm”: "Adverse event" means an incident which results in harm to a patient; "Harm" implies impairment of the structure or function of the body and/or any deleterious effect arising therefrom; "Patient safety" means freedom, for a patient, from unnecessary harm or potential harm associated with healthcare. Healthcare associated infections were the first patient safety issue addressed by healthcare workers. Today there are many other important patient safety issues (medication errors, wrong surgery, pressure ulcers, wrong transfusion, falls, etc.). REFERENCE: http://ec.europa.eu/health/patient_safety/policy/index_en.htm
- If in an healthcare organisation there is a patient safety culture established, that means that every member of staff, from senior leadership to cleaning ladies are committed to keep patients from harm. Everyone is responsible for keeping patients safe, and everyone reports adverse events. In this culture, adverse events could be minimised and many HAIs prevented. A patient safety culture has been demonstrated to be the best environment for implementing any new method or guideline for infection prevention.
- These are all elements of a patient safety culture. It has been shown that a positive organizational culture through fostering working relationships and communication across units and staff groups was evidence based in decreasing HAIs in an organization.
- The involvement of senior leadership is crucial for the development of a patient safety culture in an organization. In developing countries, due to the funds restriction, senior leadership is more focused on some other basic problems in healthcare (lack of medication and equipment, lack of educated staff, etc.) and may not focus on patient safety. In that case it is very difficult to start any successful IPC programme, and maximum engagement of IPC staff should be directed to the involvement of leadership first. In the World Health Organization’s Guidelines on Hand Hygiene in Health Care there are tools for involvement of leadership for the implementation of a safety culture. http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf
- The IPC staff should be very active in engaging not only formal leaders on wards, but also seeking champions among nursing and medical staff to support IPC practices.
- Very often when different staff are involved in the care of asingle patient, and if all staff involved are not collaborating very strongly, errors can develop. In a team, all team members are equal and all of them have the right and the responsibility to act in the best interest of patient. Therefore, every member of the team is free in observing actions of other members and freely pointing out a possible wrong action, educating each other in a friendly way, and collaborating in every step of the patient care.
- The main method IPC teams can use to influence collaborative work is when developing infection prevention policies and procedures. IPC staff should work closely with all staff involved in a specific procedure/practice and incorporate comments into the procedure. For example, when developing a procedure for insertion of central venous catheters, IPC first has to listen to staff involved (physicians and nurses). Together with their input, write the proposal for the new procedure. Then discuss this new proposal with all physicians and nurses in that particular area, including senior leaders. In such a way the ward staff will accept the new procedure as their own and everyone will know exactly what is the responsibility of a particular member of the team. Another important method of collaboration is during clinical rounds; having an open discussion about any infection with all staff members together.
- Communication is a vital aspect of patient safety. It has to be based on mutual trust during the planning and delivery of care, and setting goals to achieve best outcomes for patients. Verbal communication should be always followed by a written one; written documentation is very important to ensure clear, effective coimmunication.
- IPC staff should be good listeners; always listen to comments and problems of ward staff before giving advice. Even more importantly, the advice should be provided only after careful consideration of all ward staff comments and concerns. In this way IPC personnel will develop trust and better communication with ward staff.
- Evidence-based practice is transcribing information from science to guidelines and recommendations. Then these guidelines and recommendations should be put into policies and practices for particular patient care procedures. Staff is often reluctant to change current practice, as they “were doing this way for ever”. Evidence-based guidelines are available from WHO, US CDC, IHI and EPIC World Health Organization - http://www.who.int/csr/bioriskreduction/infection_control/en/index.html Centers for Disease Control and Prevention - http://www.cdc.gov/hai/ Institute for Healthcare Improvement - http://www.ihi.org/explore/hai/pages/default.aspx Evidence-based Practice in Infection Control - http://www.puricore.com/PDFs/Guidelines_for_Preventing_Healthcare.pdf
- When trying to implement a change in existing practices, the IPC staff may have to ask for support from leadership, find ward champions, or act as a part of a team. Implementation of a new guideline or recommendation requires tremendous effort from IPC staff, as this is possible only after removing barriers or introducing incentives. In addition, it requires theoretical learning combined with practical education and training for all ward staff involved.
- An example of organisational learning is the adoption of infection prevention “bundles” to prevent HAIs due to devices and procedures. The entire team has to learn simultaneously to think in a new way. A “bundle” is a group of several evidence-based procedures carried out by teams of caregivers, that reduce HAIs if all are implemented for every patient all the time.
- It is very important to use adult learning principles and methods in educating healthcare staff. The IPC staff should ask for help from professionals in adult learning, if they are not competent to do it themselves.
- In a patient safety culture, IPC staff use surveillance of patient risks, prevention strategies (processes) and outcomes (infections). Clinical staff should be comfortable reporting infections to the IPC team.
- Surveillance is one of the milestones of IPC: if you do not know the situation with infection risks, and incidence of infections, you cannot focus prevention efforts. Process surveillance (e.g., survey of check lists for insertion of CVC) is also very important; however without outcome surveillance you cannot be sure if your procedure is right or not. Surveillance data cannot be linearly compared with data from another ward or hospital, even not with the same ward in a different time frame. Definitions of infections may not be the same and data must be stratified whenever possible. In some countries surveillance data for some HAI are public by law, in other countries (most European and most developing countries) such data are public only as aggregated data, not pointing to a specific hospital or ward.
- Care delivery systems are often cumbersome and poorly designed, and they may interfere rather than support safe care. An example could be giving prophylactic antibiotics for surgery that seems straightforward at first glance, but is very complex: this system involves pharmacy, patient’ family, anaesthesiologists, and surgeons - together with provision, storage, transport of the drug, responsibility for dosage and time of applications, and documentation.
- “Systems” thinking is especially useful in the root cause analysis of a case of HAI.
- The objective of human factors theory is to make the work easy and successful by removing barriers and using aids. For example, check lists are helpful to assure that approved procedures are used for surgeries or insertion of central venous catheters, or the use of safety needles that reduces the risk of injury for patients and for staff.
- These are some of the key principles of human factors theory with application to IPC.
- To have sufficient availability of and easy access to material and equipment and optimised ergonomics (like hand rub at the point of care, sinks stocked with soap and single-use towels) is an evidence-based infection prevention policy.
- Since health care is delivered by humans, at some point people will inevitably make some error. A just culture adopts a “no blame” approach that focuses on the “system” that led to the error rather than on the individual. Blaming staff for errors only creates anxiety and fear and does little to solve current problems or prevent them. Eliminating blame is essential for excellence in patient care outcomes. However, a just culture does not allow for purposeful disregard of the rules. Just Culture doesn't mean a blameless culture... It does focus on processes, but Just Culture uses an algorithm to follow when mistakes are made... and if a person makes a mistake due to willful neglect or reckless behavior, then the employee is a candidate for disciplinary actions. The person's reasons for choosing their behavior are critical in the Just Culture approach to reducing error.
- Open communication and discussion with the clinical staff when an infection or outbreak happens is crucial with a “no blame” approach. Staff will then discuss freely every possible cause of that event.
- Maintaining an “improvement philosophy” approach to patient safety is crucial for safer care. Not to comply with the best practices, such as not to perform hand hygiene at appropriate times, handling infectious waste inadequately, skipping critical steps in cleaning, disinfection or sterilization – this has to be addressed and not ignored. The consequences for such behaviour should be set in advance. In the USA this concept is often ferred to as ‘zero tolerance’.
- IPC staff should continuously monitor systems and processes to find out possible new risk factors for HAIs that could decrease staff compliance to best practices (less staff due to sick leave or holidays, outbreak situation with more infectious patients, disaster with more overall patients, new procedures/equipment, new staff, etc.).
- In the future, new technologies in medicine will become even more sophisticated, and IPC evidence-based policies and procedures will become available. In an organization with a developed patient safety culture both will be easy to implement.
- True D False