Improving Quality and Safety at SVMC

Contact Patient Safety
(802) 447-4054
100 Hospital Drive
Bennington, VT 05201
mac1@phin.org

Quality and safety has always been important in health care, but only recently have hospitals focused on improving the systems that doctors and nurses use to provide care. Read on to learn more about how SVMC is working to make our hospital the safest in the nation.

Reducing Hospital Acquired Infections

Project Goal: Determine feasibility of using RFID hand hygiene monitors for inpatient nursing units to measure compliance with hand hygiene guidelines.

Summary: Hospital associated infections (HAI’s) significantly impact patient outcomes, including mortality, and contributes to increased costs of the health care system. Some studies estimate approximately 2.5 million HAI’s occur each year in the United States with costs ranging between $4.5 and $5.7 million. The Joint Commission and Centers for Medicare and Medicaid have issued directives aimed at curbing the spread of infections in hospitals. It is generally accepted that hand hygiene (achieved by using soap/water or a hand sanitizing product) reduces the spread of infection, yet it remains a challenge for hospitals to ensure that clinicians reliably engage in hand hygiene behavior. The infection prevention literature is overflowing with studies that explore the methods of measuring hand hygiene compliance including direct observation, survey/self report, and product measurement. Various methods have been utilized to measure compliance with hand hygiene behavior including direct observation, survey/self report, and analysis of the amount hand hygiene gel used. Recently, one northeast hospital tested a video monitoring system, similar to traffic light cameras, and found that this methodology was considerably more effective than direct observation by humans in measuring compliance. Other new technologies are emerging in the health care marketplace. One such technology is radio frequency identification (RFID).

This past year, SVMC formed a partnership with a leading health care technology company, Technical Solutions Group (TSG). This group had laboratory-tested an RFID hand-hygiene monitoring/measuring device and wanted to beta-test it in a hospital setting. Our hospital was eager to try something new that had the potential of reducing hospital-associated infections. Research has shown that when people know they are being monitored for compliance, their behaviors change and compliance goes up. Hence, SVMC set up a research protocol so that we could test the monitoring device in a tightly controlled manner. Before beginning the actual research, we undertook a pilot test to determine how accurately and reliably the technology would work in the hospital environment. Both TSG and SVMC agreed that the devices needed to function at a reliability rate of 95% or above.

Unfortunately, the technology did not prove to be reliable enough for us to complete the research. The pilot study involved 450 test cases; in those the device accurately read the RFID signal 386 times (86%). Of those cases, the hand hygiene sensor accurately picked up the RFID signal 261 times (68%). Although we have ended our formal research project with TSG, we continue to field test their RFID devices on site. This gives them opportunities to improve their product. SVMC remains committed to completing this initiative should the technology meet the 95% specification threshold.

Video Simulation Improves OR Communication

Project Goal: Develop a reliable process for OR team communication for pre- and post-procedure team briefings.

Project Summary: OR teams at SVMC have been doing pre-surgical briefings (called “time outs”) since 2004, when the World Health Organization created a set of patient safety guidelines. The guidelines worked to establish the expectation that team briefings are carried out, but they did not go far enough to ensure quality and reliability. As with any process, surgery included, variation creates opportunity for error. After experiencing some avoidable errors and then observing a series of OR briefings, we realized that we needed to standardize the content and tenor of the time out and post-op debriefings.

To accomplish this goal, we first developed consensus about what information needs to be part of the briefings. We relied on our colleagues at Dartmouth-Hitchcock for the content material. Next we sought agreement that each OR team performs the briefing in the same manner, every time. This level of standardization is routine in other high risk industries such as nuclear power and aviation, but has not been widely accepted in health care. With financial assistance from the Cardinal Health foundation, SVMC developed a series of teaching videos where our own physicians and nurses simulated “best practices” for how to communicate with one another before and after a surgical case, emphasizing that each step should occur in the same order every time. As a way of assisting OR teams, each of the OR rooms has a large poster with the steps on the wall and each patient chart contains a time-out checklist.

Implementation: The video was completed in September 2013. The plan is to require every surgeon, anesthesia-provider and OR nurse to watch the video and then learn how to perform it reliably. All OR staff will also be required to view the video at time of re-credentialing and / or annual competency assessment. There is also a plan to develop a video for patients to view as we feel this will help them understand how thoroughly our OR teams approach cases and review the clinical element vital to a safe and quality outcome.

Measure of Success: As with many best practices, consistent and reliable adherence to performing the Time Out has been shown to reduce the incidence of adverse patient outcomes. As such, we expect to see a reduction in preventable harm as a result of reliable adherence to the Time Out process.

Note: This project was funded by the Cardinal Health Foundation
 

Improving Transitions of Care

Project Goal: Reduce 30-day Readmission Rate from an average of 11% to an average of 8% or less.

Project Summary: Hospital readmission is a national issue. Nearly 20% of Medicare patients in the U.S. are readmitted within 30 days and the cost associated with hospital readmission is over $17 billion in 2004 (15% of total Medicare payments for hospitalization). In addition to the financial burden of readmission, it is distressing to patients and families. Research has identified evidence-based best practices that health care settings across the continuum of care can implement to reduce hospital readmissions. As such, SVHC developed an “Improving Transitions of Care” team comprised of staff from its rehabilitation and long-term care facility, the hospital, physician offices and Visiting Nurses Association to implement best practices shown to decrease hospital readmissions. When the project started, SVMC had a readmission rate that was between 12% and 10%. The goal of the “Improving Transitions of Care” team was 8% with a stretch goal of 6%.

SVMC joined a national initiative called Project BOOST – Better Outcomes for Older Adults for Safe Transitions (A national program mentored by the Society of Hospital Medicine). The Project BOOST best practices implemented at SVMC to improve patient care transitions have included:

Implementation of a “teach back” technique to gauge patient understanding of information communicated to them
Post-discharge appointments scheduled prior to discharge
Post-discharge follow-up calls made next business day after discharge
Implementation of pull systems in the medical home to follow-up with patients after hospitalization or ED visit
Implementation of electronic physician discharge orders that incorporates recommendations from all disciplines involved in patient’s care and treatment
Development and implementation of standardized discharge packet
Daily Team Huddles where case managers, pharmacists, long-term care staff, visiting nurse association representatives and social workers identify and address a patient’s risk factors for readmission during the hospital stay

As a result of these and other interventions, SVMC’s readmission rate had dropped to 9% by August 2011. The Transitions of Care Team will continue to work on this important project until we see sustained improvement of 8% or less.