The following are notes from some of the roundtables at the session held on Friday, May 15 at the AHAP conference.
This roundtable session was led by Patricia Pejakovich, senior consultant for The Greeley Company.
This discussion centered around techniques to promote good hand hygiene practices.
Some of the ideas discussed:
Patient surveys—ask patients during rounding or tracers if they have witnessed caregivers washing or sanitizing their hands often.
Secret shopper—much as a retail store employs secret shoppers, recruit a group of patients to act as
“secret shoppers” and ask them to pay attention to the frequency of staff members cleaning their hands and the manner in which they do so. Educate secret shoppers on what to look for.
“Tag, you’re it” game—this game works like the game of tag. When one staff member is observed using poor hand hygiene practices, he or she is “tagged” and is “it” until he or she observes another staff member not washing or sanitizing hands appropriately. The person who is “it” has their name posted in common, public areas so that all staff members know who is “it” at any given time. The goal, of course, is to not be “it.”
Poster campaign
“Bubble up!” campaign—staff members at one hospital took to the idea of reminding fellow coworkers to “bubble up” as a friendly way of saying “wash your hands” or “use hand sanitizer” without sounding too condescending. Some staff members are afraid of confronting coworkers about poor hand hygiene and this phrase helped break down some of the nervousness associated with doing so.
Ask seasoned nurses to speak up—this idea was specifically for those instances when physicians have been observed performing poor hand hygiene. Ask seasoned nurses at the organization who may have earned more respect from the medical staff to speak directly to these physicians about their hand hygiene practices.
Macarena—this creative idea used the “Macarena” dance song as a good way to illustrate how long staff members should was their hands for. Staff members were seen dancing while washing their hands!
Infection control baseball—this activity used the “three strikes and you’re out” theme. Any staff member observed performing poor hand hygiene would receive a “strike” from designated staff members who observed hand hygiene practices. When an employee accumulated three strikes, a note would go into his or her employee file about the poor hand hygiene practices.

CEO involvement—Get your hospital’s CEO involved by having him or her make rounds and observe hand hygiene practices. Have him or her give out candy bars to those staff members who practice exemplary hand hygiene practices. Not only does this show leadership commitment to infection control, it involves a member of the leadership team with bedside caregivers, which helps build a stronger culture of safety.
One of the leadership tables was led by Ken Rohde, consultant for The Greeley Company. Here are some of the topics discussed:
-During survey, we are seeing more concern about conflict management.
-accreditation specialists struggling with educating leaders about performance improvement initiatives and patient safety projects
-surveyors want to see “real demonstrated engagement” in patient safety and quality. You need to evaluate to see if patient safety and quality are: o -mentioned in the Board and MEC minutes o Practiced on the floor o Seen as a part of the culture present in the organization
Ask yourselves what you are doing to change the culture.
-complaint that leaders only want to talk about money, how do we get them engaged?
-successful projects have come about because the “what’s in it for me?” has been illustrated. Physicians on board, partially because they were included in the budgeting and planning processes. Example, hospital’s success with electronic medical records to encourage better medication reconciliation
-challenge to demonstrate how a new project is going to add value to the patient and organization
-demonstrated “ROI”, avoided costs. To do this, need to have a good connection with risk management
-one of the biggest issues being faces is that of accountability. Need leaders to hold people accountable before events occur, not after.
-Recent survey had a leadership accreditation focus. They were looking for:
 acceptance of leadership’s role and responsibility of building a positive patient safety culture, not for them to push those responsibilities on others.

How is leadership involved daily with these issues?

Answers from leaders to “What are you going to do about it?” for many issues

-involve COO, administrators in unit rounds. Have them take part in life safety, patient safety etc.
Joint Commission wanted to know how leadership at hospitals with outlying facilities managed to show a presence at these facilities, foster a good culture there as well. Definite challenges here, as there is one survey license for hospital system, and one CEO, COO, board of directors, but many facilities for them to tend to.
-recent surveys have shown that the focus on leadership takes place on Day 4. However, leaders need to be prepared to answer questions about accountability, ROI, and other issues for each day of survey.
Need to be held accountable for “the buck stops here” and be aware they will be during survey.
-To get leadership and physician buy-in, demonstrate benefits, costs,
This roundtable session was led by Larry Poniatowski, Principal Consultant for Accreditation Compliance
Services, University HealthSystem Consortium
Issues Identified:

To implement the Universal protocol appropriable the organization needs strong medical staff leadership support.

Bedside procedures are the most difficult for organizations to insure cooperation and monitor compliance.

Indent-bands are covered quite often when the patient is draped for the procedure, making it impossible to use this as a source of patient identification for the final time-out.

The ED wants to define every procedure as an emergency thereby circumventing the need to perform the universal protocol. Not all procedures performed in the ED are actually emergency procedures.

Once an organization gets staff cooperation TJC changes the actual requirements, or clarifies an unclear requirement. This erodes the credibility of those responsible for implementing the UP.
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There are still some physicians who are refusing to cooperate with either marking the site of the final time-out.

There is frequently a disconnect between the pre-procure and procedure area.

Time-outs have become perfunctory, and all items that need to be covered are not.


Surveyors are inconsistent in their comments.

Can residents who are performing the procedure mark the site and conduct the final time-out?

Alternate site-marking is a problem.
This roundtable session was led by Barb Swanson, QI/Accreditation manager for The Rehabilitation
Institute of Chicago.
The topic was appropriate for round table discussion. Even though the NPSG has been around for awhile and does not currently exist on the top 10 Joint Commission most challenging standards list there was enough inquiry to suggest that some healthcare organizations still are struggling with establishing a successful process.
Documentation Requirements:
Participants were reminded that “Documentation” for hand-off communication was not a Joint
Commission NPSG requirement. Participants shared comments that indicated that the majority were using one or both of the two following tool formats:

Electronic

Paper
Tools Utilized:
Participant indicated the tools used to support their Hand-off process:

Paper Tools mentioned: o “SBAR”: A popular acronym / tool that represents key elements to remember when providing important information to the appropriate receiver.
 S = Situation
 B = Background
 A = Assessment
 R = Report o “SHIFT” for Shift Report: An acronym similar to the above SBAR tool but formatted differently. “SHIFT” is the mnemonic adopted as a standardized format in one organization for shift to shift report. Nurses use this format when giving report.
 S = Situation
 H = Happenings
 I = Interventions
 F = Follow-up needed
 T = Timing

o “Ticket to Ride” / “Quick Trip Ticket”: An organizational customized form that provides key individualized patient information to the next care provider. The form may include items such as:
 precautions
 special needs
 care alerts
 demographic information o “Patient Care Kardex / Profile”: A worksheet that condenses all of the key information for the delivery of care, treatment, and services. o Physician Progress Notes for Physician Hand-off reports are being used in some settings:
 Staff indicated the physicians were paged for clarification or questions. o Note:
 A couple of organizations stated their computer systems provided a mechanism for having the electronic version of SBAR and / or Ticket to Ride tools.
 One organization representative indicated they actually shared the form with the patient and / or family members. This would demonstrate active engagement by patient and family involvement in the care of the patient.

Verbal Tools mentioned: (All had steps in their process to include an opportunity for the receiver to clarify and / or ask questions.) o Daily / Shift Taped Report o Daily / Shift Team Huddles o Daily / Shift Bedside Report (off-going to incoming)
How do we know if we are doing a good job at “hand-off”? Examples of check points provided: o Observation o RCA information o Sentinel Event information o Incident Reports o Medication Error Reports
Questions / Issues brought to the round table discussion:
1.
Wanted to learn from others on how they implemented their process.
2.
Wanted to learn from others on how they measured process effectiveness.
3.
Wanted to learn from others on how they achieved physician compliance with the process.
4.
Wanted to hear “Best Practices”.
5.
Wanted to learn from others on how to minimize interruptions.
6.
Having difficulty with hand-off process between nursing and ancillary departments.
7.
Having difficulty with hand-off process between nursing and radiology.
8.
How to improve upon the hand-off process to / from 7 PM – 7 AM with House Physicians.

9.
Challenges encountered with ED hand-off to inpatient areas.
Additional Comments:
CMS: Two organizations stated they had CMS in their facilities recently and CMS did inquire about their hand-off processes. CMS did not specifically call the process “Hand-off”. However, CMS was looking at how the reporting of care was delivered.
Computer Directed Hand-off:
A very brief discussion on what is used as a backup if the computer goes down.
Hospitalists:
Those that spoke to the topic of physician Hospitalists all indicated processes that were working very well.
Training Tools:
Some participants offered that their organizations use training tools to orientate and educate staff on the hand-off process. One example stated was the use of a laminated sheet.
Creating the Process:
Be sure to include the right people when setting up a process.