(S TANDARD O PERATING P ROTOCOLS ) IN H OSPITALS W ORLDWIDE The High - - PowerPoint PPT Presentation

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(S TANDARD O PERATING P ROTOCOLS ) IN H OSPITALS W ORLDWIDE The High - - PowerPoint PPT Presentation

Apr 07, 2024 409 likes •771 views

S IGNIFICANT I MPROVEMENTS IN P ATIENT S AFETY U SING H IGH 5 S SOP S (S TANDARD O PERATING P ROTOCOLS ) IN H OSPITALS W ORLDWIDE The High 5s Project was launched in 2006 by WHO and the WHO Collaborating Center on Patient Safety TJC to

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#E5 #Quality2015

@WHO

SIGNIFICANT IMPROVEMENTS

IN PATIENT SAFETY USING HIGH 5S SOPS

(STANDARD OPERATING PROTOCOLS)

IN HOSPITALS WORLDWIDE The High 5s Project was launched in 2006 by WHO and the WHO Collaborating Center on Patient Safety – TJC to address three specific patient safety problems around the world. High 5s Steering Group Members 20th International Forum on Quality and Safety in Healthcare 21-24 April 2015, London, UK

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#E5 #Quality2015

@WHO

Australia France Germany The Netherlands Singapore Trinidad & Tobago United Kingdom United States of America Canadian Patient Safety Institute & Institute for Safe Medication Practices Canada Agency for Healthcare Research and Quality WHO Collaborating Centre for Patient Safety – The Joint Commission WHO

HIGH 5S PROJECT

www.who.int/patientsafety/implementation/solutions/high5s/en/

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#E5 #Quality2015

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  • 1. Overview of the High 5s SOP materials for your

country and local hospital/healthcare setting

  • 2. Strategy to adapt the High 5s SOPs in your

country/healthcare setting in collaboration with relevant stakeholders

  • 3. Action plan to implement the High 5s SOPs in your

local healthcare setting and involve patients as partners to optimize significant impact of SOPs on patient safety

SESSION GOALS

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Claire Chabloz

Haute Autorité de Santé, France

Rick Croteau

American College of Surgeons, USA

Anupam Dayal

The Joint Commission, USA

Carolyn Hoffman

Alberta Health Services, Canada

Agnès Leotsakos

World Health Organization, Switzerland

Erica vdS-de Loos CBO

Dutch Institute for Healthcare Improvement, NL

SESSION ADVISORS

@Adayaljcr @PatVei @carolyn0715

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SESSION CONTENT

  • A. SOP Instruction

Plenary

  • C. SOP Implementation

Round Table Discussion II SOP @Home Messages

  • B. SOP Adaptation

Round Table Discussion I Wrap Up

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  • A. STANDARD OPERATING PROTOCOL

(SOP) INSTRUCTION

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STANDARD OPERATING PROTOCOL (SOP)

Set of instructions for implementing a defined process in a consistent and measurable manner by multiple users

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  • 1. Standard Operating Protocols: SOPs
  • 2. SOP implementation guides
  • 3. Significant improvements in patient safety in 7 countries

SOP INSTRUCTION

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2010-2015: Implementation and Evaluation Standardized solutions within a global learning community To achieve measurable, significant, and sustained reductions in challenging patient safety problems

1.Is this feasible? 2.Will it make a difference?

SOPS – MISSION

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  • 1. Correct Site Surgery
  • 2. Medication Reconciliation
  • 3. Safe Management of

Concentrated Injectable Medicines Rationale for standardizing Less variation Fewer errors Better outcomes Comparability and portability

SOPS – 3 PATIENT SAFETY CHALLENGES

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Multi-dimensional Approach Measurement, evaluation, and process management Quantitative: Process and outcome measures Qualitative implementation evaluation: questionnaires and interviews Reporting, feedback, succes stories Culture surveys and event analysis

SOPS – EVALUATION

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Problem Wrong site or procedure/implant/person surgery Scope Cases done in an inpatient operating room setting Site marking requirement limited to cases involving laterality, or multiple surfaces, structures or levels Solution Extended preoperative verification process Surgical site marking Final “time out” before incision

  • 1. CORRECT SITE SURGERY SOP
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Pre-Op Verification Check List Why use a check list?

  • 1. A guide for consistent implementation
  • 2. A documentation tool
  • 3. A data collection tool

CORRECT SITE SURGERY SOP

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Problem Medication errors at points of transition in patient care process Scope All patients at all entry points and all transitions in care Solution Complete and accurate list of patients’ home medication, on admission Using the list when writing medication order Identify and resolve discrepancies ≤24 hours: safe prescribing

  • 2. MEDICATION RECONCILIATION SOP
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Problem Prevention of medication errors associated with preparation, storage and administration of CIM Scope Concentrated potassium chloride solution Sodium heparin (>1000 units/milliliter) Injectable morphine preparations Solution Minimize look-alike labeling and packaging Segregate storage from other medicines Limit amount of CI drugs stored in all clinical areas

  • 3. CONCENTRATED INJECTABLE MEDS SOP
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  • B. STANDARD OPERATING PROTOCOL

(SOP) IMPLEMENTATION GUIDES

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To assist front line hospital staff and leaders in achieving smooth and successful SOP implementation

  • Issue
  • Why Use SOP
  • Impact

Overview

  • Who, When,

Where & How

  • Resources &

References

Step by Step & Keep It Stupidly Simple

  • Measurement for

Improvement

  • Lessons Learned

Process Management, Evaluation & Feedback

IMPLEMENTATION GUIDES

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SOPs

Standardized process Implementation strategy Process management strategy

IMPLEMENTATION GUIDES & SOPS

www.who.int/patientsafety/implementation/solutions/high5s/en/

& SOP Process Flow Charts

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Seek and investigate events that should have been prevented by the SOP and report specific de-identified information Types

Concise Comprehensive

Compiling Events

Aggregate Cluster

Events Identified

CSS Independently reported AEs Prospective SOP checklist review Med Rec Indepentent reported AEs Independent observer chart audits

IMPLEMENTATION GUIDES: EVENT ANALYSIS

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Correct Site Surgery: equipment Med Rec: staffing, policy and procedure, environment

IMPLEMENTATION GUIDES: EVENT ANALYSIS

Recommended Change: Clinical Med Review at Time of Med Rec

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  • C. SIGNIFICANT IMPROVEMENTS

IN PATIENT SAFETY IN 7 COUNTRIES

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The SOPs are Feasible

Correct Site Surgery: 38 hospitals, 5 countries Medication Reconciliation: 58 hospitals, 5 countries

SIGNIFICANT IMPROVEMENTS

  • Barriers
  • Competition with existing

patient safety priorities

  • Resistance to change
  • Insufficient education and

training

  • Limited ressources
  • Maintaining engagement
  • Key Points for

Success

  • Management buy-in
  • Multidisciplinary work
  • On site champions:

pharmacists, surgeons etc

  • Leadership
  • Communication
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The SOPs Did Make an Impact

Correct Site Surgery

No wrong-site surgeries reported Barriers to measuring outcomes

Incomplete reporting and infrequent events (Low-N)

Positive outcomes (good catches) more useful

Medication Reconciliation

Baseline versus complexity of process (variables) makes measurement of improvement challenging (process)

SIGNIFICANT IMPROVEMENTS

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France: 8 participant hospitals, 10 surgery specialties

SIGNIFICANT IMPROVEMENTS

Risk awareness Culture change

Sharing Community

High 5s is relevant for

  • ut patients

Quality of wok life improved Other safety projects induced

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France Positive Error Culture: 29 good catches in 6 hospitals

SIGNIFICANT IMPROVEMENTS

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SIGNIFICANT IMPROVEMENTS

Netherlands

From National Patient Safety Program & Guidelines (‘08/’09) to Global High 5s in 2009 to strengthen implementation

VdS-De Loos et al., 2010-2013

Med Rec ≤ 24 hours: 0% 40% > 90%: 100%

Reduction of discrepancies: ≥ 75% reduction < 1-5 months Hospital wide policy on Concentrated Injectable Medicines

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Pharmacist-based Med Rec reduces medication discrepancies in acute hospital admissions of elderly patients “Investment on this staff pays for itself quickly” “Hospitals require the Med Rec SOP and SOPs are generic enough.” “The SOP has been totally integrated in the system of

  • ur hospital.”

SIGNIFICANT IMPROVEMENTS

Vd Bemt PM, VdS-dL EM et al. The Dutch CBO WHO High 5s Study Group. Doi 10.1111/jgs.12380 Dutch Inspectorate of Health: IGZ 2012: De Veiligheid telt : p.27, 28} VdS-dL, 2014

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  • SOPs across multiple hospitals and countries with

minimal variation improved related hospital processes and patient care SOP Implementation and Evaluation

  • Hospital processes
  • Leadership
  • Safety culture

SIGNIFICANT IMPROVEMENTS: OVERALL BENEFITS

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  • Limited resources and know-how at hospital level
  • Implementation and data collection challenges
  • Internal and external resistance to change
  • Poor providers’ knowledge of existing policies and procedures
  • Insufficient education and training, policies/procedures for safety

lacking, ineffective teamwork by leaders and providers

  • Poor exchange of patient/organizational information and

communication

  • Competition with existing in-country patient safety priorities

SIGNIFICANT IMPROVEMENTS: OVERALL BENEFITS

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#E5 #Quality2015

@WHO

1. Name a standardization of a care process applied in your country/facility What positive impact has it had on patient safety? What were the challenges? If standard of care processes have not been applied in your facility, what potential benefits/challenges do you anticipate? 2. How would you integrate the SOPs into the existing processes

  • f care in your country/facility?

How do you anticipate the challenges and opportunities? With Use of the SOP Flow Charts bmj.co/handouts

SOP ADAPTATION

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#E5 #Quality2015

@WHO

What resonated with you?

High 5s Steering Group Members 20th International Forum on Quality and Safety in Healthcare 21-24 April 2015, London, UK

www.who.int/patientsafety/implementation/solutions/high5s/en/

SOP ADAPTATION WRAP UP

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#E5 #Quality2015

@WHO

  • 1. What are the first steps to initiate an action plan in your

facility for implementing the SOPs?

  • 2. How can the action plans be integrated within existing

resource, processes, and stakeholders in your country/facility? With Use of the High 5s Action Plan Template bmj.co/handouts

SOP IMPLEMENTATION

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#E5 #Quality2015

@WHO

What did you hear in the discussion that you will remember to take home?

High 5s Steering Group Members 20th International Forum on Quality and Safety in Healthcare 21-24 April 2015, London, UK

www.who.int/patientsafety/implementation/solutions/high5s/en/

SOP @HOME MESSAGES

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#E5 #Quality2015

@WHO

SIGNIFICANT IMPROVEMENTS

IN PATIENT SAFETY USING HIGH 5S SOPS

(STANDARD OPERATING PROTOCOLS)

IN HOSPITALS WORLDWIDE The High 5s Project was launched in 2006 by WHO and the WHO Collaborating Center on Patient Safety – TJC to address three specific patient safety problems around the world. High 5s Steering Group Members 20th International Forum on Quality and Safety in Healthcare 21-24 April 2015, London, UK

www.who.int/patientsafety/implementation/solutions/high5s/en/