Nicola (RN BSN LNC CPHQ CPSO) has been working in the healthcare industry for nearly two decades and has years of experience writing policies for hospitals, as well as reviewing policies for regulatory compliance. She is on the Joint Commission’s exclusive list of consultants that assist staffing agencies and other healthcare entities with certification and accreditation. In addition to consulting in healthcare policy and procedures, she is also a certified legal nurse consultant and a certified patient safety officer.
[PolicyMedical Webinar] Policies and Procedures for Patient Safety
Nicola Heslip, Director of Product Content Management at PolicyMedical Nicola (RN BSN LNC CPHQ CPSO) has been working in the healthcare industry for nearly two decades and has years of experience writing policies for hospitals, as well as reviewing policies for regulatory compliance. She is on the Joint Commission’s exclusive list of consultants that assist staffing agencies and other healthcare entities with certification and accreditation.YOUR PRESENTER: NICOLA HESLIP Your Webinar Host: Daisy Jiang Marketing Specialist PolicyMedical
WEBINAR POLICIES & PROCEDURES FOR PATIENT SAFETYWebinar AgendaPart I: Educating Staff on Patient Safety MeasuresPart II: How To Discover Patient Safety ChampionsPart III: The ROI of Patient SafetyPart IV: Where Practice Meets Policy for Fall Prevention
Part I: Educating Staff on Patient Safety Measures
Patient safety principles should be part of yourorganization’s core. Your foundation.
At orientation, all employees should understand howthey can directly or indirectly impact patient care.Situational awareness.
Have a discussion with staff about JUST CULTURE. Demonstrate how staff should report patient events.
Demonstrate how staff should report patientevents.
Management should be trained by HR about corrective action.Follow a standardized model (eg. James Reason’s model)
Part II: How To Discover Patient Safety Champions
Who can be a patientsafety champion?• Executives• Managers• Front line staff• Housekeepers
Engaging a PatientSafety Champion3.Ask a manager – they knowtheir staff5.Round on a unit and talk tostaff about patient safetytopics7.Attend a leadership meetingabout recruiting patient safetychampions9.Talk to the CMO aboutrecruiting physicians
Keeping a PatientSafety Champion3.Give them access toeducation material (eg. coremeasures)5.Help them buildrelationships (eg. with PSO/PIteam)7.Tap into their leadershipqualities & passions9.Give them timeRecommended reading: “Role of championsin the implementation of patient safetypractice change” from Healthcare Quarterly12 (sp) 2009:123-128 by Soo et al (Universityof Toronto)
Patient satisfaction results drag down hospitals’value-based purchasing (VBP) scores.
Through the “Hospital Compare” program, CMS will use VBPto calculate Medicare reimbursements.
Meade, Bursell and Ketelsen: nurses who performed hourlyrounds increased patient satisfaction.
Wong and Cummings: found connection between leadership’spositive behavior & decrease in adverse events
Weingart et al: patient incidents reflected a deficiency in“service” (eg. waits, delays, communication breakdowns)
Next Steps:Understanding the Patient Safety & Patient Satisfaction Link4. Actively engage patients & families in patient safety initiatives6. Have staff complete a culture of safety survey8. Analyze the results of both employee and patient satisfaction surveys10. Focus on nursing comments12. Focus on communication of clinical information scores14. Look at trends with patient complaints, employee feedback & adverse events16. Review ratings related to the admission process18. Look at ratings related to the discharge process20. Look at noise ratings22. Be proactive!
“I’m much more likely to judge a hospital experience on thecommunication skills of the nursing staff & physicians...”
When staff don’t have the tools they need to find procedures,they are dissatisfied & display negative behavior to patients.
Part IV: Where Practice Meets Policy for Fall Prevention
1/3 of the elderly over 65 years falls each year. Falls account for25% of all hospital admissions and 40% of all nursing homes.
Use an evidence based tool (eg. Morse or John Hopkins) toassess fall risk.
ATTENTION: your policies should explain what fall risk toolthe hospital is using. Policies & practice should match.
Folks most at risk are older than 85 years and...
Fall Prevention• Validate the process with tracers and staff interviews• Vet the documentation• Chart review• Visit the patient and family• Fall reduction and performance improvement• Have a team• Recruit a champion• Share the data• PDCA
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