CHPSO Patient Safety News February 2010, Vol. 2 No. 2
Contents
- About This Newsletter
- New Partnership Launched With Anthem Blue Cross
- SAVE LIVES: Clean Your Hands
- Debriefing Can Be Valuable Tool in Quality Improvement
- CHPSO/Quantros Web Portal Now Live; Free Web Seminar Offered
- WHO Surgical Checklist News
- Event Calendar
- Article Submission
About This Newsletter
CHPSO Patient Safety News provides lessons learned from reviews of patient-safety events and news of patient-safety activities in this state. We hope you will find it useful in your efforts to improve patient outcomes. This newsletter may be freely distributed in its original form. Copies of each newsletter will be archived on the CHPSO website (www.chpso.org). Send subscription requests (additions, deletions) to ltate@calhospital.org. Article submission information is at the end of this newsletter.
New Partnership Launched With Anthem Blue Cross
Anthem Blue Cross, along with California’s three Regional Hospital Associations and the National Health Foundation have announced they are joining together in a three-year, $6 million effort to improve the quality and consistency of care Californians receive. The Ronald Reagan UCLA Medical Center hosted the launch of Patient Safety First… a California Partnership for Health, a unique relationship that will save lives, improve the quality of medical care and reduce health care costs to make health care more affordable for the people of California.
This new partnership will support collaborative improvement efforts for member hospitals in each of California’s Regional Hospital Associations: the Hospital Council of Northern and Central California, the Hospital Association of Southern California and the Hospital Association of San Diego and Imperial Counties.
The three initial areas of focus will be perinatal care, sepsis, and hospital-acquired infections in the ICU setting.
For information on programs in your area, please contact:
Hospital Association of San Diego and Imperial Counties
Judith Yates, Regional Vice President
858-614-0200
jyates@hasdic.org
Hospital Association of Southern California
Catherine Carson, Vice President of Quality & Performance Improvement
213-538-0789
ccarson@hasc.org
Hospital Council of Northern and Central California
Mary Lopez, Sr. Vice President, Quality
559-650-5692
mlopez@hospitalcouncil.net
SAVE LIVES: Clean Your Hands
On May 5, 2010, the World Health Organization (WHO) will again issue a global call to action inviting health care workers throughout the world to actively campaign for improved hand hygiene to reduce health care-associated infections (HAIs) and demonstrate their commitment to this important global movement.
The WHO Patient Safety Initiative was launched May 5, 2009, and supported by more than 5,000 hospitals and health care facilities from 125 countries that had already registered their commitment.
Now, the WHO Patient Safety Initiative aims to double the level of commitment to 10,000 by May 5, 2010. Professor Didier Pittet, external lead for WHO’s First Global Patient Safety Challenge, “Clean Care is Safer Care,” encourages all health care facilities to register their support at www.who.int/gpsc/5may/register/en/index.html.
To mark May 5, 2010, the WHO Patient Safety Initiative will:
- Broadcast a live web seminar by Professor Pittet from Geneva, Switzerland.
- Issue a simplified hand-hygiene observation tool based on one of the WHO’s “My 5 Moments for Hand Hygiene” to focus health care workers on taking action at the point of care by monitoring compliance. This monitoring can be undertaken May 5, as well as on a regular basis to improve practices and ensure patient safety.
- Release data from pilot test sites around the world where hospitals have trialed the WHO multimodal hand-hygiene improvement strategy using WHO evaluation tools to monitor their hand-hygiene compliance, as well as other areas such as their perceptions and knowledge of hand hygiene and HAIs.
HAIs place a serious disease burden and significant economic impact on patients and health care systems throughout the world. WHO is committed to encouraging and supporting good hand hygiene everywhere. The simple task of cleaning hands in the right way and at the right time at the point of patient care can save lives. Take action now and utilize the WHO resources that are available at www.chpso.org/hygiene/index.asp.
Debriefing Can Be Valuable Tool in Quality Improvement
Debriefing is a process-improvement tool that consists of a recap of events after a shift or procedure. Designed to capture lessons learned and defuse conflict, debriefing has been routine in aviation for decades, and more recently has been adopted by other professions and businesses bent on quality improvement.
Some health care organizations have hit a bit of a speed bump when they attempt to implement debriefing. Specifically, when teams use a prompt such as “What can we do better?” they find that people are very reluctant to speak up. One reason frequently cited for withholding information relates to concerns about public embarrassment because “I should have known that.”
In their emerging role as clinical leader of an interdisciplinary team, physicians and other practitioners can facilitate greater self-disclosure of opportunities for improvement by setting the standard. The urologist who says to the circulating nurse, “I didn’t realize that this was the first time you’ve done a case like this. I could have taken more time telling you exactly which specimens we would need,” is likely to elicit a response from that nurse along the lines of, “I should have told the whole OR team during the pre-op briefing that it was my first time with this procedure.”
Admitting your area for improvement requires personal courage and professional commitment. The benefits of fostering trust by demonstrating vulnerability are greater organizational transparency and stronger, safer teams.
— Steven Montague lifewings@verizon.net, Vice President, LifeWings
CHPSO/Quantros Web Portal Now Live; Free Web Seminar Offered
The California Hospital Patient Safety Organization (CHPSO)/Quantros web portal is now live. CHPSO and Quantros are holding a complimentary web seminar Feb. 4 from 10 a.m. – 11 a.m. to introduce the CHPSO/Quantros web portal and tour its features.
Member hospitals will have free access to a number of valuable services and information through this web interface, including simple point-and-click submission of incident reports to CHPSO; hospital-specific analysis of their submitted incident reports, with benchmarking; peer collaboration through secure access to web communication and social networking portals; and a patient-safety resource library, including topical content for general items, event-specific resources, regulatory changes and alerts.
To participate in the seminar, contact La Shon Tate at 916-552-7616 or ltate@calhospital.org
WHO Surgical Checklist News
Both the California Hospital Patient Safety Organization and the California Hospital Association consider the improvement of surgical safety as essential to public health and endorse the concept of the “WHO Surgical Safety Checklist.” The checklist reduces the chance of overlooking important information at three points during the patient’s care: at check-in, at the time-out and at the end of the case.
The Society of Thoracic Surgeons has now adapted the WHO checklist for three specific settings: adult cardiac surgery, general thoracic surgery and congenital heart surgery. Hospitals are welcome to use the checklists and change as needed.
Additionally, noted author Atul Gawande has just published The Checklist Manifesto: How to Get Things Right (Metropolitan Books). “Gawande is a gorgeous writer and storyteller, and the aims of this book are ambitious. Gawande thinks that the modern world requires us to revisit what we mean by expertise: that experts need help, and that progress depends on experts having the humility to concede that they need help.”—Malcom Gladwell.
— Rory Jaffe, MD MBA rjaffe@calhospital.org
Event Calendar
Following is a list of upcoming events that are still open for enrollment. For more information or to enroll, use the contacts listed below.
February
4: CHPSO: CHPSO/Quantros Web Portal. Free Web Seminar. 10 a.m. – 11 a.m.
10: BEACON: PSQI, Practical Skills for Quality Improvement. Event cancelled.
11: BEACON: Compass Series course day 2 (of 4). Fremont.
16: HASD&IC (Hospital Association of San Diego & Imperial Counties): San Diego Patient Safety Council. San Diego.
18: BEACON: Key Contacts Meeting. San Francisco.
March
4: BEACON: Physician Leadership Meeting. San Francisco.
5: BEACON: CNE Meeting. Location to be determined.
10: BEACON: PSQI, Practical Skills for Quality Improvement. Location to be determined.
11: BEACON: Compass Series course day 3 (of 4). Santa Clara.
12: CAPSAC: California Patient Safety Action Coalition Meeting. Sacramento.
April
7: HASD&IC: San Diego Patient Safety Council. San Diego.
8: (Date change — was April 15) BEACON: Compass Series course day 4 (of 4). Santa Clara.
14: BEACON: PSQI, Practical Skills for Quality Improvement. Location to be determined.
27: BEACON: Annual Meeting. Santa Clara.
30: CAPSAC: Statewide Convening. Sacramento.
May
12: BEACON: PSQI, Practical Skills for Quality Improvement. Location to be determined.
13: BEACON: Compass Series course day 1 (of 4). Location to be determined.
13: BEACON.: Leadership Council. Location to be determined.
June
2: HASD&IC: San Diego Patient Safety Council. San Diego.
9: BEACON: PSQI, Practical Skills for Quality Improvement. Location to be determined.
10: BEACON: Compass Series course day 2 (of 4). Location to be determined.
11: CAPSAC: California Patient Safety Action Coalition Meeting Pasadena.
July
8: BEACON: PSQI, Practical Skills for Quality Improvement. Location to be determined.
9: BEACON: Compass Series course day 3 (of 4). Location to be determined.
27: BEACON: Quarterly Meeting. Location to be determined.
August
11: BEACON: PSQI, Practical Skills for Quality Improvement. Location to be determined.
12: HASD&IC: San Diego Patient Safety Council. San Diego.
12: BEACON: Compass Series course day 4 (of 4). Location to be determined.
September
8: BEACON: PSQI, Practical Skills for Quality Improvement. Location to be determined.
9: BEACON: Compass Series course day 1 (of 4). Location to be determined.
10: CAPSAC: California Patient Safety Action Coalition Meeting Napa.
10: BEACON: Key Contacts Meeting. Location to be determined.
23: BEACON: Physician Leadership Meeting. Location to be determined.
24: BEACON: CNE Meeting. Location to be determined.
October
6: HASD&IC: San Diego Patient Safety Council. San Diego.
December
1: HASD&IC: San Diego Patient Safety Council. San Diego.
3: CAPSAC: California Patient Safety Action Coalition Meeting. Torrance.
For further information on these events:
BEACON: Pamela Speich pspeich@hospitalcouncil.net or www.beaconcollaborative.org
CAPSAC: Theresa Manley manleyt1@pamf.org or www.capsac.org
CHPSO: Rory Jaffe rjaffe@calhospital.org
HASC: Catherine Carson ccarson@hasc.org
HASD&IC: Nancy Pratt nancy.pratt@sharp.com
Article Submission
Prospective authors may submit articles to Rory Jaffe, MD, MBA (rjaffe@calhospital.org, 916-552-7568). Typical articles will be brief — between 200 and 600 words. Additional information may be provided as web links. If accepted, the additional information may be hosted on the CHPSO website.
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