Patient Safety and Total Quality Council
Highlights from the May meeting of the Patient Safety and Total Quality Council follow. The council is chaired by Richard Lippe, MD.
Blood Usage and Transfusion Committee
Darrell Triulzi, MD, director, Division of Transfusion Medicine, noted that a new process was established for real-time review of red blood cell utilization through UPMC’s electronic medical record system. When an order is placed for RBCs, a review of current lab results will be completed. If the patient’s last hemoglobin or hematocrit does not meet the target goal for transfusion, the eRecord system will generate an alert informing the practitioner that the order does not meet institutional transfusion guidelines.
Current guidelines set the pretransfusion hemoglobin level at ≤ 8.5 g/dL and ≤ 7.5 g/dL for intensive care unit patients. Patients with acute coronary syndromes should be maintained at a hemoglobin level ≥ 10 g/dL.
Care Management
Victoria Zombek, director, Care Management, noted that average length of stay for patients in observation status continues to increase.
In March 2010, Care Management implemented a project to place observation notification stickers on patient charts. These stickers remind physicians that the patient is in observation status and a decision needs to be made to admit the patient or to discharge. The stickers made a slight impact in the six- to seven-day observation rates. It is recommended that after 48 hours of observation, the patient either needs to be discharged or admitted.
As part of the test of change implemented in March, an observation notice form is placed in the progress note, and department chairmen receive daily notifications of observation patients not discharged on day three.
Patient satisfaction (inpatient)
Karen Robinson, manager, Patient Relations, presented information about how Patient Navigators have begun to round to complete patient education activities and conduct wellness visits. These rounds have increased scores in key areas of the Press Ganey survey and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.
Long-term strategies are in development to facilitate ongoing patient satisfaction. These strategies call for involvement of Patient Navigators in additional nonclinical support roles. Efforts planned are:
- a partnership with Quality Improvement to study the feasibility of assisting with call bell response
- working alongside care provider staff during the discharge process (serving as an educator)
- providing support to ancillary units such as Transport during high census
Patient Safety and Risk Management
Topics discussed by Lisa Painter, director, Patient Safety and Risk Management, included resources developed to help UPMC staff manage difficult patient encounters. These tools are designed to help physicians and staff identify, manage, and deal with difficult patient encounters and address disruptive patient and visitor behaviors, including the use of profanity; verbal arguments or physical violence; rude, racist, or culturally insensitive remarks; threats; displays of weapons; and drug or alcohol abuse.
The goal of this effort is to minimize disruptions in the provision of care by following fair and consistent processes. Once a disruptive or difficult patient behavior or situation is identified, direct caregivers should activate their departmental chain of command and notify Security. If the situation is not resolved, subsequent steps can be taken to involve the patient’s physician of record and other appropriate staff to issue a notice of noncompliance and explore alternative care methods.
With assistance from clinical and administrative leadership, teams can develop an individualized response to each situation. These responses may include a change in the plan of care, a change in visiting privileges, issuance of a notice of noncompliance, or exploration of alternative care options, among others.
Resources to assist staff are available on Print-on-demand. Place Shadyside in the location filter and review the documents under Nursing Forms. Documents to use in managing difficult patient encounters are:
- Notice of noncompliance
- Outpatient treatment for continued care
- Smoking letter
- Visitor contract
For more information, review UPMC Presbyterian Shadyside policy MA-21, Patient and Visitor Code of Conduct (April 20, 2010).
Senior care
Amelia Gennari, MD, UPMC Senior Care–Shadyside, discussed quality projects in which the Plan, Do, Study, Act (PDSA) performance improvement model was used to achieve goals for patient care.
One of the goals was to increase completion rates on the Vulnerable Elders Survey-13 (VES-13) for patients with diabetes. The survey is a 13-item questionnaire for screening community-dwelling populations to identify older persons at risk for health deterioration. The VES-13 considers age, self-rated health, limitations in physical function, and functional disabilities.
Steps taken were:
- The office manager started calling patients and administering the VES-13. It became clear this was too much work for one person.
- Completion of the calls was made an educational opportunity for a social work student intern (September 2009 to April 2010).
- A process needed to be created to continue VES calls after the student completed the internship.
- The Epic electronic medical record system team was instructed to design a program to send an e-mail to the office manager listing patients to be seen the next day and their most recent LDL and HgbA1C data. The office manager reviews the list and calls the patient before office hours if no VES score listed.
- More calls are being placed to patients who did not have a documented VES score. This process also has helped UPMC Senior Care–Shadyside determine that 26 percent of its patients with diabetes are in the very frail classification.