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Contest entry: Hand hygiene

Another tip, another entry for free registration at this year’s 2009 AHAP Conference! The latest comes from Mary Lou Love, MSN, RN, infection control practitioner out of Edinburg, TX. She writes:

To enhance hand hygiene we had one of our leaders submit his picture and placed his picture on the screensaver along with our message on hand hygiene so that his peers and all of our healthcare providers would see that we all want to make a difference. He said we all need to jump in and help where ever we can.

Joint Commission revises… revised standards

The Joint Commission has, after discussion with CMS, reduced the number of changes from its January 5, 2009 announced standards revisions. According to the official announcement, the changes followed discussion with CMS (and Joint Commission’s deeming authority application) during which it was determined that a number of the requirements were already covered under existing standards or otherwise in the Joint Commission survey process.

The Joint Commission has published the changes here. A crosswalk of the March and January standards revisions is available here.

Stay tuned for further analysis…

Positive Deviance proven to lower MRSA rates

The Robert Wood Johnson Foundation and Plexus Institute today announced the results of a Positive Deviance program, trialed to see the effects it had on MRSA rates. The story caught my eye because I’ve written a couple of stories about Positive Deviance for Briefings on Patient Safety in 2007 and 2008, and the idea always struck me as something so simple, yet so empowering. Positive Deviance solicits ideas for solving a problem from those who deal with that problem often and may think of a solution that might be considered “out of the norm,” but one that works. It’s an approach that attempts to gather behavioral change from those frontline workers who solve problems with the same resources as their peers.

Using Positive Deviance to lower MRSA rates has succeeded, as it was announced at the annual scientific meeting of the Society for Healthcare Epidemiology of America this past weekend. The study began in 2006 and introduced the idea of Positive Deviance into three hospitals from different parts of the country. Each hospital was to use Positive Deviance to help carry out the following three actions:

  • screening all patients admitted to a pilot unit for MRSA
  • isolating all patients who tested positive
  • rigorously adhering to hand hygiene and contact precautions

A team from the Centers for Disease Control and Prevention analyzed the data from these facilities to show a reduction in MRSA rates between 26 and 62%.

This video clip from CBS News shows how one transporter helped his hospital adhere to hygiene and contact precautions (sorry about the commercial before the news).

Could this technique be something your hospital implements? Have you thought of using Positive Deviance for tackling other issues at your facility, not just MRSA?

You can find out more about Positive Deviance by visiting the Positive Deviance Initiative Web site.

Contest entry: Unannounced survey plan

Today’s first entry into our contest comes fromJanelle Holth, RN, BSN, regulatory compliance coordinator at Altru Health System. She sent in the attached survey preparation switchboard, with the following description:

We had our first unannounced survey in October 2008. Our “Unannounced Survey Plan” assisted our entire organization to be well prepared to welcome the survey team to our facilities. I worked with a committee consisting of 8 employees (Executive leadership, managers, coordinators) from various areas in our health system. As this committee gathered information, we would meet every two weeks to design and update the Unannounced Survey Plan. Once the plan was finalized, education about the plan was brought to all levels of leadership. We subsequently scheduled two mock surveys (about 6-8 months apart) allowing us to test our plan and make necessary changes. The goal of utilizing this plan was to assure good communication to our survey team and the employees of our health system. We believe that organization and communication are key to setting the tone of the survey from the moment the surveyors enter our front lobby. Detail was added to the survey plan so that all staff involved were well aware of their duties.

We functioned with a “command center” all week. The command center was equipped with computers, a printer and staffed by a minimum of 3 employees. Information flowed in and out of our command center allowing us to bring surveyors and escorts policies, guidelines and documents timely if requested. The command center managed the day to day operations, scheduling for special sessions and directed communications to appropriate staff. Executive leadership contacted this center for updates on the progress of the survey.

Staff were available and involved with tracer activities and special sessions. The survey team observed the “culture of safety” set forth by our leadership team and commended our staff for their compassionate patient care.

The survey team thanked us for being prepared, organized and responsive to their requests during the exit briefing. I believe the detailed design of our unannounced survey plan assisted employees to be involved and ready for a survey. The command center was a vital component for day to day operations throughout the survey process.

The switchboard can be downloaded here:


Thanks for a great entry, Janelle!

More continuous survey tips

Ladies and gentlemen, our fourth entry of the day in our AHAP Conference registration giveaway. Our latest comes fromCathy Rowden, accreditation director at Skaggs Regional Medical Center in Branson, MO. She writes:

Each survey we pick a theme to help promote awareness for the survey. This year’s theme is “survivor.” We kicked it off with a National Patient Safety Goal day of learning. We had stand up posters made by each national patient safety goal team to remind staff of the goal. We decorated the rooms in less than 30 minutes, had refreshments, music, video’s going on national patient safety goals that we produced. People love to see themselves and co workers on the screen, and it was a huge success. Not labor intensive. Gave away several prizes for attendees. Following that we did a power point presentation on line for those that were unable to get to the event.

Finally we followed up with an online test covering all the national patient safety goals. It was a hit, it tells us where our “trouble” spots might be, and the staff loved it.

Screen savers as education tools

Another entry to the contest! This comes fromMichael Neiman, MHA, CPHQ, senior director of accreditation/regulatory affairs at Thomas Jefferson University Hospitals in Phiadelphia, PA. His tip:

We utilize our screen savers to communicate reminder information to staff as part of continuous survey readiness. Information includes National Patient Safety Goals, Performance Improvement, Infection Control, Environment of Care, Medical Record Documentation, and Patient Satisfaction results. This serves as constant reminders and has been extremely effective with communication. We keep them current and change them every few weeks.

Next up: National Patient Safety Goals

the entries for our AHAP Conference registration giveaway keep coming in. Here’s another tip, fromCarla Brown, RN, patient safety officer and clinical leader for the emergency department at Forest Park Hospital. Her story:

Our hospital held an event to review National Patient Safety Goals, accreditation requirements, and other mandatory subjects. It was required of all employees, clinical and non-clinical. Employees were scheduled to attend at specific times.

To make it fun and memorable for everyone, we created a nautical theme. Titled “Cruise to Excellence,” we had numerous “ports of call” which focused on various educational topics. Team members depicted the “crew” from Gilligan’s Island, actually was a “3 hour cruise.” We randomly assigned teams, who competed against each other to win prizes (such as lunch at the Forest Park Boathouse with our CEO). We even had a grand prize of an actual cruise! We spoke “pirate,” we sang karaoke at “Forest Park Idol”, and we sent shipmates to the “Poop Deck” if they didn’t cooperate. It was great fun, employees bonded with each other, everyone’s morale was boosted, and best of all….performance reviews showed marked improvements in safety and quality measures after the Cruise! We proved that everyone (from dietary aide to security officer to nurse, and so on) was better able to follow through with what was taught when the lessons were interactive, energetic and fun!

Contest continues with a site marking tip

Let’s start the day with yet another entry in our 2009 AHAP Conference registration giveaway. Our first tip today comes from Barbara Swisher, RN, quality coordinator of Abilene Regional Medical Center in Abilene, TX. She wrote:

This year we are very fortunate to have an active Chief of Staff. He is a general surgeon who never really understood site marking to its full intention. After some education, he was “on board” to educate the remainder of the Medical Staff. He deserves full credit for our successful program. First he wanted education in several forms: A construction sign with a flashing light used for recent renovations was placed in the Physicians’ Dining area with information on site marking and the cautions to take – laterality, level, etc. Then each physician on staff received a certified letter with a small clickie Sharpie ® with the words “Yes Marks the Site.”

A date was set where the C of S, CNO, COO, Surgical Services Director, Invasive Radiology Director, Cath Lab Director, and Quality Director met in the Day Surgery Unit (DSU) at 6 pm where they would be able to “further educate” any physician with questions or opposition. No patient who required site marking was allowed to leave the DSU without the LIP marking the site. The sites are now marked by the Surgeon in the DSU, occasionally with a little under-the-breath speech, with the patient actively involved and the DSU staff documenting on the Universal Protocol form.

More tips yet to come today–keep those entries coming!

Contest entry: Continuous readiness

Our latest entry comes fromTricia Elliott, coordinator of accreditation and licensure in the quality/patient safety department at St. Alexius Medical Center in Hoffman Estates, IL. Her tip:

For our 2009 PPR, we are having small group meetings with the content experts for each chapter. During the meeting we are online with the PPR tool, and scoring the individual EPs. There is room on the PPR tool to enter additional information that is needed (or researched) to determine compliance, or an action plan is developed for a non-compliant EP. Those EPs that are not at satisfactory compliance are brought to a Task Force for further review and additional input into the action plan process to ensure the appropriate steps are taken to become compliant. Also, the Task Force pays special attention to the “challenging” standards published by The Joint Commission to ensure continuous readiness and compliance in the more challenging areas.

Contest entry: PPR tip

Another entry! This one comes from Lisa Kulp, RN, MS, CPHQ, accreditation specialist at Grant Medical Center.  Her tip:

When it is time to conduct the annual PPR assessment tool for Joint Commission standards, we have also added a review of the CMS Conditions of Participation standards at the same time. This will assist our facility to conduct a more thorough review of the standards that we are expected to be in compliance with at all times.