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Improving Patient Safety in Nursing Homes: A Resource List

Improving Patient Safety in Nursing Homes: A Resource List for Users of the A HRQ Nursing Home Survey on Patien t Safety Culture Pur pose This document contains references to Web sites that provide practi cal re sources Nursing homes can use to implement ch an ges to improve Patient Safety culture and Patient Safety . This Resource list is not exhaustive, but is provided to give initial guidance to Nursing homes looking for information about Patient Safety initiatives. This document will be updated periodically. How T o U se This Resour ce Li st Resource s are listed in alphabetical order, organized by the composites assessed in the Agency for Healthcare Res earch and Quality (AHRQ) Nursing Home Survey on Patient Safe ty Culture (av ailable at Safety /patientsafetyculture/ Nursing - ), followed by general resources.

Long-Term Care Improvement Guide. Long-Term Care Toolkit. Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient . Safety Practices Making Your Printed Health Materials Senior Friendly Medically Induced Trauma Support Services (MITSS) Multimorbidity Pocket Card

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Transcription of Improving Patient Safety in Nursing Homes: A Resource List

1 Improving Patient Safety in Nursing Homes: A Resource List for Users of the A HRQ Nursing Home Survey on Patien t Safety Culture Pur pose This document contains references to Web sites that provide practi cal re sources Nursing homes can use to implement ch an ges to improve Patient Safety culture and Patient Safety . This Resource list is not exhaustive, but is provided to give initial guidance to Nursing homes looking for information about Patient Safety initiatives. This document will be updated periodically. How T o U se This Resour ce Li st Resource s are listed in alphabetical order, organized by the composites assessed in the Agency for Healthcare Res earch and Quality (AHRQ) Nursing Home Survey on Patient Safe ty Culture (av ailable at Safety /patientsafetyculture/ Nursing - ), followed by general resources.

2 For easy access to the resources, keep the file open rather than printing it in hard co py b ecause the Web site URL s are hyperlinked and cross-referenced resources are bookmarked within the document. NOTE: The resour ces included in this document do not constitute an endorsement by the Department of Health and Human Services (HHS), the Agency for Healthcare Research and Quality (AHRQ), or any of their e mployees. HHS does not attest to the accuracy of information provided by linked sites. Suggestions for tools you would like added to the list, questions about the survey, or requests for assistance can be addressed to: Prepared by: Westat under contr act number HHSA 290201300003C for the Agency for Healthcare Research and Quality Updated February 2016 2 Contents Resources by Composite.

3 6 Composite 1. Overall Perceptions of Resident Safety .. 6 Composite 2. Feedback and Communication About Incidents .. 7 Composite 3. Supervisor Expectations and Actions Promoting Resident Safety and Composite 4. Management Support for Resident Safety .. 8 Composite 5. Organizational Learning .. 8 Composite 6. Training and Skills .. 10 Composite 7. Compliance With Procedures .. 12 Composite 8. Teamwork .. 13 Composite 9. Handoffs .. 13 Composite 10. Communication Openness .. 15 Composite 11. Nonpunitive Response to Mistakes .. 15 Composite 12. Staffing .. 16 General Resources .. 17 Falls Management/Prevention .. 23 Pressure Ulcer Reduction .. 24 Pain Management .. 27 3 Al phabetical I ndex of Resources 2014 National Healthcare Quality and Disparities Report: Chartbook on Patient Safety 2015 Long Term care National Patient Safety Goals AHRQ Impact Case Studies, NEW AHRQ Patient Safety Education and Training Catalog AHRQ s Safety Program for Nursing Homes: On-Time Prevention Always Events Tool box Applying High Reliability Principles to Infection Prevention and Control in Long Term care , NEW Appoint a Sa fety Champion for Every Unit Best Practice Intervention Packages for Fall Prevention Braden Scale for Predicting P ressure Sore Risk CAHPS Improvement guide CAHPS Nursi ng Home Surveys Call to Action.

4 Safeguarding the Integrity o f Healthcare Quality and Safety Systems, NEW Centers for Medica re & Medicaid S ervices (CMS): Survey & Cer tifica tion - Certi fication & Compliance Conduct Patient Safety Leadership WalkRounds Consistent Assignment, NEW Cooperative Network Improves Patient Transitions Betw een Ho spitals and Skilled N ursi ng Facilities, Reducing Readmissions and Length of Hospital Stays Coordinated-Transitional care Toolkit Creation of Households Program in Nursing Home Improves Residents Health Status, Reduces Staf f Turnover, and Boosts Demand for Services Daily Skin care Flow Sheet Decision Tree f or Unsafe Acts Culpability Department of Defense Patient Safety Program Toolkits Department of Veteran Affai rs Na tional Center for Patient Safety Falls Toolkit Enhanced Toileting Program Reduces Incontinence and Its Comorbiditi es Among Residents of Long-Term care Facility Enhancing t he Management o f Neuropathic Pain in the Long-Term care Setting Facts about the Official Do Not Use List, NEW Falls Free: Promoting a National Falls Prevention Action Plan Falls Management Program Get Connected!

5 Toolkit: Linking Older Adu lts With Medication, Alcohol, and Mental Health Resources guide for Developing a Community-Based Patient Safety Advisory Council, NEW guide to Implementing Quality Improvement Principles Hand Hygiene in Healthcare Settings, NEW Hand Hygiene in Outpatient care , Home-Based care , and Long-Term care Facilities Hea lthcare Provider Tool kit Home-Like, Self-Direct ed Environment Provides Sup erior Quality of Life Than in T raditional Nursing Homes and Assisted Livi ng Facilities How-To guide : Improving Transitions From t he Hospital to Skilled Nursi ng Facilities To Reduce Avoi dable Rehospitalizations How-To guide : Prevent Pressure Ulcers IMP ACT ( Improving Mood: Promoting Ac cess to Collaborative Trea tment for Late-Life Depression) Im provi ng Patient Safety in Long-Term care Facilities: Training Modules 4 Inst itute for Healthcare Improvement: Plan-Do-Study-Act (PDSA) Worksheet Interdisciplina ry Te am Identifies and Addresses Risk Factors f or Falls Among Nursing Home Re sident s, Leading to Fewer Falls and Less Use of Restraints Interventions To Reduce Acute care Transfers (INTER ACT) ISMP s List of Confused Drug Names, NEW Just In Time Toolkits for Staffi ng Transformation Leadership Response to a Sentinel Event.

6 Respectful, Effec tive Crisis Management Long-Term care Improvement guide Long-Term care Toolkit Making Health care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices Making Your Printed Health Materials Senior Friendly Medically Induced Trauma Support Services (MITSS) Multimorbidity pocket Card Nati onal Blueprint: Increasi ng Physical Activity Among Adults Age 50 and Older Nati ona l Nursi ng Home Q uality care Collaborative: Change Package Nati onal Quality Strategy Stak eholder Toolkit Nursing Home Neighborhood s Emphasize Dignity and Independence, Leading to Improvements in Resident Health and Quality of Life and Lower Employee Turnover Nursing Home Quality Initiative Old er Ad ults : Designing Health Information To Meet their Needs Partnership To Improve Dementia Ca re in N ursing Homes: State Coalition Provider Question Worksheet Patient - and Family-Centered care Organizational Self-Assessment Tool Pa tient Fall Prevention and Management Protocol with Toileting Program Pa tient Safety and the Just Culture : A Presentation by David Marx, Pa tient Safety Primer.

7 Medica tion E rrors Pa tient Safety Primer: Safety Culture Pa tient Safety Primer: Teamwork Training Pa tient Safety Self-Assessment Tool Person-Centered care , NEW Pioneer Netwo rk Pressure Ulcer Baseline Assessment Survey for Registered Nurses and Nursing Assistants Pressure Ulcer Clinica l Tools & Resources Pressure Ulcer Prevention: A Nursing Competency-Based Curriculum Pressure Ulcer Prevention Points Preventing Pressure Ulcers Turn Clock Tool Prevention and Treatment Program Integrates Actionable Reports Into Practice, Significantly Reducing Pressure Ulcers in Nursi ng Home Residents Primary care P rovider Fax Report and Orders Provide F eedba ck to F rontli ne Staff Quality Improvement Fundamentals Toolkit Quality Improvement Savings Tracker Worksheet SAFER Guides Safety Huddle Results Collection Tool Same Page Transitiona l care Resources for Patients and care Partn ers SBAR Techni que for Communication: A Situational Briefing Model Skin care Facts.

8 Pressure Ul cer Prev ention Staff Stability, NEW Staf f Training and Support, Incentives, and Feedback Fails To Generate Sustainable Reductions in Pressure Ulcers at Nursing Home 5 Staying Healt hy T hrough Education and Prevention (STEP) TeamSTEPPS Long-Term care Version, NEW TeamSTEPPS Re adiness Assessment Tool Try T his: Best Practices in Nursing C are to Older Adults University of Michigan Health System Patient Safety Toolkit: Disclosure Chapter Department of Veterans Affairs Nationa l Center f or Patient Safety Root Cause Analysis WHO Patient Safety Implementing Change Wil l It Work Here?: A Decisionmaker s guide to A dopting Innova tions 6 Resources by Composite The following resources a re organized according to the relevant Nursing Home Survey on Patient Safety Culture composites they can help improve.

9 Some resour ces a re duplicated and cross-referenced because they may apply to more than one composite. Composite 1. Overall Perceptions of Resident Safety 1. Making Health care Saf er II : An Upda ted Critical Analysis of the Evidence for Pa tientSafety This evidence report is featured on the AHRQ Health care Innovations Exchange Web site. It presents practices relevant to Improving Patient Safety , focusing on hospital care , Nursing homes, ambulatory care , and Patient self-management. It defines Patient Safety practices, provides a critical appraisal of the evidence, rates the pract ices, and identifies opportunities for future research. 2. Patient Safety Self-Assessment This organizational self-assessment tool was designed by S teven Meisel, PharmD, at Fairvie w Health Services using information from a report published by the Agency for Healthcare Res earch and Quality (AHRQ) in Rockville, Maryland, USA.

10 The tool can help staff members ev aluate whether known Safety practices a re in p lace in their organizations and to find areas for imp Patient Safety Primer: Safety The concept of Safety culture originated outside health care , in studies of high-reliability organizations. These organizations consistently minim ize adverse ev ents despite carrying out intrinsically complex and hazardous work. High-reliability organizations maintain a commitment to Safety at all levels, from frontline providers to managers a nd ex ecutives. This commitment establishes a culture of Safety . The AHRQ Patient Safety Network explains this topic further and provides links for more in formation on what is new in Safety culture.


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