Stony Brook Medicine Response to Quality Assurance and Performance Improvement Overview
Stony Brook Medicine developed corrective actions in response to deficiencies identified by the DOH/CMS related to patient care and compliance. Implementation strategies include education, training, and validation processes. The healthcare facility's approach emphasizes a culture of accountability and continuous improvement.
Download Presentation
Please find below an Image/Link to download the presentation.
The content on the website is provided AS IS for your information and personal use only. It may not be sold, licensed, or shared on other websites without obtaining consent from the author. Download presentation by click this link. If you encounter any issues during the download, it is possible that the publisher has removed the file from their server.
E N D
Presentation Transcript
Stony Brook Medicine: Response to Quality Assurance and Performance Improvement What We Need to Know New York State Department of Health Center for Medicaid Medicare Services [CMS] All Cause Corrective Action Stony Brook Medicine Developed 6/10/2015 Reviewed 6/19/2015 cm The Stony Brook Way is My Way
DOH/CMS Areas of Deficiency: 1. Allegations of Sexual, Physical, or Psychological Abuse 2. Infection Control Practices 3. Intravenous Therapy and Blood Product Administration 4. HIPAA, as it relates to PHI Disclosure 5. Code Cart Standardization The Stony Brook Way is My Way
IMPLEMENTATION /COMMUNICATION STRATEGY 1. Didactic education 2. Skills based training and Simulation 3. Attestation- confirmed completion 4. Validation- check performance 5. Outcomes- compliance The Stony Brook Way is My Way
CMS ALLEGATION SURVEY DOH for CMS Allegation survey 4/28/15 5/4/15 Finding related to process for investigation of patient complaints of Abuse & Neglect by a Staff member Actions: New Policy RI0057: Patient Allegations of Abuse/Neglect by a Staff Member implemented prior to DOH exit Education to front line, managers, supervisors, directors & medical staff via PPs, LMS, and continuing through annual re-certifications and new employee orientation Abuse Complaint checklist to document actions Policy: RI:0057 https://policymanager.uhmc.sunysb.edu/dotNet/documents/?docid=6063 &mode=view The Stony Brook Way is My Way
CMS REPORT 5/13/2015 CMS document received evening of 6/3/2015 (on day 3 of TJC Survey) Follow up actions and clarification statements to be submitted by 6/15/2015 Requires 100% education : Medical Staff must complete to 100% by 6/15/2015 Requires 100% monitoring of responses to Abuse & Neglect complaints (13 to date since DOH visit) Requires feedback to Departments on Abuse & Neglect complaints Requires tracking & trending by department and individual The Stony Brook Way is My Way
HEALTHCARE EPIDEMIOLOGY DEPARTMENT Administrative Policy on Isolation Precautions IC 0006 As soon as patients are identified as needing isolation: Yellow card / chart, dedicated stethoscope / thermometer All rooms must have a Personal Protection Equipment [PPE] cabinet in or in close proximity to the entryway Cabinets must be stocked with gowns, gloves, surgical masks, goggles and / or face shields All HCWs are responsible for following the isolation precautions delineated in the Hospital Policy and reminding other HCWs to do the same Families must be educated re: Hand hygiene practices and Patient s isolation The Stony Brook Way is My Way
HEALTHCARE EPIDEMIOLOGY DEPARTMENT All patients, regardless of status: inpatient outpatient observation Must be placed on the correct isolation precautions based upon the patient s: personal history clinical presentation isolation code on Banner Bar The Stony Brook Way is My Way
DEPHEALTHCARE EPIDEMIOLOGY DEPARTMENT ORMATICS Administrative Policy on Hand Hygiene IC 0003 Hand Hygiene is performed: Upon entering & exiting patient rooms Before and after any contact with patient / environment, regardless of +/- isolation status In between dirty and clean procedures Between separate portions of the physical exam re: clean vs dirty OK to foam when entering a C diff room, but must wash hands with SOAP / WATER upon exiting Families must be educated on hand hygiene practices The Stony Brook Way is My Way
HEALTHCARE EPIDEMIOLOGY DEPARTMENT Administrative Policy on Infection Control in patient transporting IC 0007 Patients on isolation must be transported using practices that minimize cross contamination If patient is on isolation, the transporter must: Perform hand hygiene, don correct PPE identified on the isolation yellow card before entering room Bring clean transfer equipment into the room, transfer patient to stretcher or wheelchair as indicated Cover patient with clean sheet Remove isolation garb before exiting room, perform hand hygiene When transferring patient on occupied bed, wipe the side rails and all accompanying equipment with antimicrobial (purple) wipes, allowing for 2 minute dwell time prior to exiting the room The Stony Brook Way is My Way
Administrative Policy on Infection Control in Patient Transporting IC 0007 Patients on droplet and airborne precautions must themselves wear a well fitted surgical mask during transport prior to leaving the room to contain their secretions, thus preventing dissemination All other patients do not require a mask as the mode/mechanism of transmission is not via droplet secretion The Stony Brook Way is My Way
HEALTHCARE EPIDEMIOLOGY DEPARTMENT Health Care Providers are NOTto carry multi-dose vials in pockets or case (pharmacy policy modified): From patient to patient From room to room When used on a patient with an infection, discard after use Use single-dose containers whenever possible When single-dose dispensers are not available: Maintain aseptic technique Perform hand hygiene Prevent tip of dispenser from touching the patient Wipe down container with antimicrobial (purple) wipes in between every patient encounter and prior to returning it to the case. The Stony Brook Way is My Way
SBU Hospital Infection Control Policies Hand Hygiene IC 0003 Multidrug Resistant Organisms (M-RO) IC 0010 Patient Care Equipment Cleaning IC 0013 Infection Control In Patient Transporting IC 0007 Isolation Precautions IC 0006 Prevention and Control of Clostridium defficile IC 0022 Prevention and Transmission of M. Tuberculosis infection IC 0011 MM0012 Multiple Dose Vials, Multiple Use Containers IC0012 Standard Precautions Infection Control is in Your Hands
All consultants [MDs, NPs, PAs, etc] will notify primary nurse of their arrival prior to entering patient room in ED and on the Units: I m here to see patient ____. Is there anything I should know? The Stony Brook Way is My Way
IV THERAPY AND BLOOD ADMINISTRATION Audit and analysis of all IV and Blood Administration Policies Development of educational materials aligned with best practices and SBUH policies Development of Skills Training stations Development of Simulation scenarios Training of Auditors Systematic ongoing monitoring The Stony Brook Way is My Way
HIPAA COMPLIANCE: PROTECTED HEALTHCARE INFORMATION Removed complete patient name from slave monitors Rolling computer carts: instructing and auditing for open EMRs with PHI on the screen Education on the proper communication of PHI, with instruction for sensitivity to the environment and other people: only permitted use of incidental disclosure The Stony Brook Way is My Way
CODE CART STANDARDIZATION All Pediatric and Adult Code Carts now include the appropriate Zoll Pads Pediatric Code Cart now contains two sets of Zoll Pads: Children less than 8 years of age and over 8 years of age All Code Carts now have consistent Code Cart checklists The Stony Brook Way is My Way
ALL CAUSE CORRECTIVE ACTIONS Accountability Attestation of all staff by 6/15/2015 Validation of training and education 6/15-6/20/2015 Remediation directives-as it occurs Behavior-Based Expectations- continuous Ongoing monitoring of outcomes Patient Safety Rounding will include CMS Hospital Infection Control Worksheet with relevant scoring. The Stony Brook Way is My Way
