Source: 5-Diamond Patient Safety Program data collected online, Final Diamond Status table/file, 2014 and 2015;. DFCompare 2015-10-08 and DFCompare ...
5-Diamond Patient Safety Program Data Review, 2014 and 2015 August 2016 5diamondpatientsafety.org esrdnet5.org
Table of Contents 2014 and 2015 Chartbook 1. 2. 3. 4. 5.
5-Diamond Patient Safety Program Overview and 2015 Highlights 5-Diamond Patient Safety Program Participation Comparison of Non-Diamond and 1-5 Diamond Facilities Patient Safety Principles Module Thank You to Participants and Sponsors
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Section 1: 5-Diamond Patient Safety Program Overview and 2015 Highlights
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5-Diamond Patient Safety Program Overview BACKGROUND
Medical errors are the 5th leading cause of death in the United States* THE PROGRAM The 5-Diamond Patient Safety Program is an innovative training and recognition program designed to assist dialysis facilities in building a culture of safety among staff and patients
4 OBJECTIVES
Promote patient safety values
Create an awareness of patient safety issues
Source/Note: *Institute of Medicine Report 1999
Help dialysis facilities learn more about specific areas of patient safety
Build a patient safety culture in every dialysis facility
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5-Diamond Patient Safety Program Overview 14 MODULES
Each is a complete educational course with the following available online: • Objectives • Measures • Required & Optional Activities • Tools & Resources • PowerPoint presentations questionnaires, pre- and/or post-tests to engage staff • Posters, games, and activities to engage patients Patient Safety Principles
Communication
Constant Site Cannulation
Emergency Preparedness
Hand Hygiene
Health Literacy
Influenza Vaccination
Medication Reconciliation
Missed Treatments
Patient-Provider Conflict
Sharps Safety
Slips, Trips & Falls
Stenosis/ Vascular Access Monitoring
Transplantation
5-DIAMOND FACILITIES
Dialysis facilities completing 5 modules are recognized as 5-Diamond Patient Safety organizations and can promote their accomplishments to their patients 5
5-Diamond Patient Safety Program
1,290
PARTICIPATING FACILITIES
543
5-DIAMOND RECIPIENTS
13 PARTNER NETWORKS
1 out of 5 nationwide
2015 HIGHLIGHTS
22,591
STAFF TRAINED
91,554
PATIENTS CARED FOR
TOP 6 NETWORKS* FOR 5-DIAMOND STATUS
2 CORPORATE
COMMITMENTS SINCE 2014 IN 2016
2 RESOURCES REQUESTED
4
MOST POPULAR MODULES
PATIENT SAFETY PRINCIPLES**
SLIPS, TRIPS, & FALLS
IN-SERVICE TRAINING FOR STAFF
HAND HYGIENE
INFLUENZA VACCINATION
EDUCATIONAL MATERIALS FOR PATIENTS
Source: 5-Diamond Patient Safety Program data collected online, Final Diamond Status table/file, 2015 Notes: *DCI facilities are included in Network numbers. **Mandatory module.
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Section 2: 5-Diamond Patient Safety Program Participation
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5-Diamond Patient Safety Program Participation Chart 2.1: High-Level View of Facility Participation,* 2014 and 2015
15% increase
1,290
TOTAL FACILITIES
15% increase
PATIENTS CARED FOR
79,771
1,125
11% increase
543
5-DIAMOND RECIPIENTS
STAFF TRAINED
16% increase
22,591
19,521
490
2015
91,554
2015
2014
2014
The 5-Diamond Program is growing Source: 5-Diamond Patient Safety Program data collected online, Final Diamond Status table/file, 2014 and 2015 Notes: *“Participants” refers to dialysis facilities that registered for the 5-Diamond Patient Safety Program. Patients do not participate in the 5-Diamond Program.
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5-Diamond Patient Safety Program Participation Chart 2.2: Rate of Participation* and Receiving 5 Diamonds** by Ownership, 2015 79%
• 62%
•
• 29%
•
20% 15%
15%
9%
8% 2%
2%
• DAVITA
DCI % PARTICIPATION
FMC
OTHER
TOTAL
20% of all facilities nationally participated in the 5-Diamond Program in 2015 Since 2014, DCI has made a corporate commitment to have all facilities participate DCI and independent facilities had higher rates of participation and 5-Diamond achievement than DaVita and FMC This program seems especially valuable to SDOs*** and independent facilities which may have fewer educational resources than the LDOs**** FMC has committed all of its facilities to participating in 2016
% 5-DIAMOND RECIPIENTS
Source: 5-Diamond Patient Safety Program data collected online, Final Diamond Status table/file, 2014 and 2015; DFCompare 2015-10-08 and DFCompare 2014-10-23 databases Notes: *Participants include all facilities that registered for the 5-Diamond Program, earning 0 to 5 Diamonds. **5-Diamond Recipients are participating facilities that earned 5 Diamonds. ***Small Dialysis Organizations ****Large Dialysis Organizations. This chart shows the % of the LDO/SDO/independent/total facilities that participated in the 5-Diamond Program and earned 5 Diamonds. 9
5-Diamond Patient Safety Program Participation Chart 2.3: Ownership Distribution of Program Participants* and 5-Diamond Recipients,** 2014 and 2015 Participants
5-Diamond Recipients 53%
59% 60%
49%
27% 26% 22%
20% 15%
DAVITA
17%
14%
DCI
11%
FMC 2014
2015
10%
OTHER
6%
DAVITA
5%
DCI
8%
FMC 2014
OTHER
2015
Source: 5-Diamond Patient Safety Program data collected online, Final Diamond Status table/file, 2014 and 2015; DFCompare 2015-10-08 and DFCompare 2014-10-23 databases Notes: *Participants include all facilities that registered for the 5-Diamond Program, earning 0 to 5 Diamonds. **5-Diamond Recipients are participating facilities that earned 5 Diamonds. This chart shows the % of total participating facilities that were LDO/SDO or independently owned as well as the % of total 5-Diamond facilities that were LDO/SDO or independently owned. Percentages are rounded to the nearest integer. 10
5-Diamond Patient Safety Program Participation Chart 2.4: Network Partners, 2015 16 11
17
15
12
1 10
4
9 5 6
18
13 8 14
3
•
13 of 18 Networks partnered with MARC in administering the 5Diamond Program (shown in blue)
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16
3
3
17
17
17
Source: 5-Diamond Patient Safety Program data collected online, Final Diamond Status table/file, 2015 Note: Partner Networks, those in which the Network office/staff administered the program, are represented in blue.
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5-Diamond Patient Safety Program Participation Chart 2.5: Percentage of Network Facilities That Participated in 5-Diamond Program, 2015 6
45%
3
35%
2
31%
15
27%
11
26%
5
24%
NETWORK #
8
22%
9
19%
12
19%
4
•
18%
14
15%
18
13%
1
12%
16
8%
10
•
13 of 18 Networks partnered with MARC in administering the 5-Diamond Program (shown in blue) Facilities from non-partner Networks were managed by a partner Network Tended to be higher rates of participation within partner Networks
8%
13
5%
17
5%
7
•
3%
Source: 5-Diamond Patient Safety Program data collected online, Final Diamond Status table/file, 2015; DFCompare 2015-10-08 database. Notes: DCI facilities are included in Network numbers. This chart includes 0-5 Diamond recipients. Partner Networks, those in which the Network office/staff administered the program, are represented in blue.
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5-Diamond Patient Safety Program Participation Chart 2.6: Percentage of Network Facilities That Received 5 Diamonds, 2015 11
19%
2
16%
4
15%
8
15%
15
12%
5
10%
NETWORK #
12
9%
3
8%
9
8%
1
7%
14
6%
16
6%
17
3%
13
3%
7 18
•
8%
6
10
•
•
13 of 18 Networks partnered with MARC in administering the 5-Diamond Program (shown in blue) Facilities from non-partner Networks were managed by a partner Network Tended to be higher rates of receiving 5 Diamonds within partner Networks
2% 1% 1%
Source: 5-Diamond Patient Safety Program data collected online, Final Diamond Status table/file, 2015; DFCompare 2015-10-08 database. Notes: DCI facilities are included in Network numbers. This chart includes 0-5 Diamond recipients. Partner Networks, those in which the Network office/staff administered the program, are represented in blue.
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5-Diamond Patient Safety Program Participation Chart 2.7: Facility Participation by Program Module, 2015 PATIENT SAFETY PRINCIPLES
60%
HAND HYGIENE
37%
SLIPS, TRIPS, & FALLS
19%
INFLUENZA VACCINATION
18%
COMMUNICATION
10%
TRANSPLANTATION
9%
CONSTANT SITE CANNULATION
9%
HEALTH LITERACY
8%
SHARPS SAFETY
8%
EMERGENCY PREPAREDNESS
7%
STENOSIS/VASCULAR ACCESS…
7%
PATIENT-PROVIDER CONFLICT
6%
MISSED TREATMENTS MEDICATION RECONCILIATION
•
•
•
Hand Hygiene and Influenza Vaccination top the list and have a large impact on patients’ health Medication Reconciliation is complex and a leading cause of healthcare-related mistakes Patients would benefit if more facilities completed the Medication Reconciliation module
4% 1%
% OF 5-DIAMOND PARTICIPATING FACILITIES WHICH COMPLETED THE MODULE Source: 5-Diamond Patient Safety Program data collected online, individual modules’ tables/files, 2015
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Section 3: Comparison of Non-Diamond and 1-5 Diamond Facilities 15
Comparison of Non-Diamond and 1-5 Diamond Facilities Slide 3.1: Reason for Non-Diamond Facilities
• •
Networks have used 5-Diamond Patient Safety Program modules for quality improvement initiatives Therefore, dialysis facilities have registered for the program to gain access to the modules, but have not applied for Diamond status, resulting in non-Diamond participating facilities
Source: 5-Diamond Patient Safety Program data collected online, Final Diamond Status table/file, 2014 and 2015
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Comparison of Non-Diamond and 1-5 Diamond Facilities Chart 3.2: Comparison of Staff and Patients Represented by Non-Diamond Facilities and 1-5 Diamond Facilities, 2014 and 2015 2014
AVERAGE STAFF
2015
20
AVERAGE STAFF
15
80
AVERAGE PATIENTS REPRESENTED
67
NON-DIAMOND
1-5 DIAMOND
19 17
78
AVERAGE PATIENTS REPRESENTED
73
NON-DIAMOND
1-5 DIAMOND
1-5 Diamond facilities tend to have slightly fewer staff and patients represented per facility
Source: 5-Diamond Patient Safety Program data collected online, Final Diamond Status table/file, 2014 and 2015
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Comparison of Non-Diamond and 1-5 Diamond Facilities Chart 3.3: Rural/Urban Distribution of Non-Diamond Facilities and 1-5 Diamond Facilities, 2015
69% 80%
1-5 Diamond facilities have a larger proportion of rural facilities compared to non-Diamond facilities and the national proportion of 22%*
31% 20% 0 DIAMONDS
1-5 DIAMONDS RURAL
URBAN
Source: 5-Diamond Patient Safety Program data collected online, Final Diamond Status table/file, 2015; Rural/Urban from CMS CY-2013-Final-ESRD-PPS-Facility-Level_Impact-File.xls Note: *In 2013, 22% of facilities nationwide were rural.
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Section 4: Patient Safety Principles
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Patient Safety Principles Module Table 4.1: Overview of Participation in Patient Safety Principles Module,* 2015 Chart 4.2: Distribution of Staff Completing Patient Safety Principles Module, 2015
Management 6%
FACILITIES
Other 16%
Patient Care Technicians 36%
773
STAFF
13,456
PATIENTS REPRESENTED
51,943
PCTs can get CEUs for this module
Physicians 6%
Nurses 33%
Equipment Technicians 3%
Source: 5-Diamond Patient Safety Program data collected online, Final Diamond Status file/table, 2015; Patient Safety Principles file/table, 2015 Notes: *Mandatory module. Facilities are the participants in the 5-Diamond Program. Staff receive training through the 5Diamond Program. Patient numbers are those cared for at participating facilities. Patients do not participate. 20
Patient Safety Principles Module Chart 4.3: Percentage of Positive* Responses for Safety Attitudes Questionnaire, Q1-Q4, 2015 1. Is it easy for personnel here to ask questions when there is something that they do not understand? 94.7
92.5 89.2
2. I have the support I need from other personnel to care for patients.
94.9
92.6
88.5
87.6
86.7
83.2
0-11
12-15 16-19 20-24 # OF FACILITY STATIONS
25 or more
82.0
0-11
12-15
16-19
20-24
3. Important issues are well communicated at shift changes. 88.2
4. Briefings are common in this clinical area. 85.0 82.1
82.5 76.9
75.3
74.7
74.5 69.1
69.5
0-11
12-15
25 or more
# OF FACILITY STATIONS
16-19
20-24
# OF FACILITY STATIONS
25 or more
0-11
12-15
16-19
20-24
25 or more
# OF FACILITY STATIONS
In smaller facilities, staff were more likely to answer the questions positively Source: 5-Diamond Patient Safety Program data collected online, Patient Safety Principles file/table, 2015; DFCompare 2015-1008 database. Notes: *Positive responses are “always” and “frequently.” Patient Safety Principles is a mandatory module. 21
Patient Safety Principles Module Chart 4.4: Percentage of Positive* Responses for Safety Attitudes Questionnaire, Q5-Q8, 2015 5. My suggestions about safety would be acted upon if I expressed them to management. 89.7
6. We are informed about errors that happen in this facility. 87.3
86.9 82.8
86.7
83.3
83.2
82.6 76.8
76.6
0-11
12-15 16-19 20-24 # OF FACILITY STATIONS
25 or more
90.9
86.6
12-15
16-19
20-24
25 or more
# OF FACILITY STATIONS
7. We discuss ways to prevent errors from happening again.
91.7
0-11
8. After we make changes to improve patient safety, we evaluate their effectiveness. 87.3
85.7
84.9 80.9
82.0
80.4 75.5
0-11
12-15
16-19
20-24
# OF FACILITY STATIONS
25 or more
0-11
12-15
16-19
20-24
25 or more
# OF FACILITY STATIONS
In smaller facilities, staff were more likely to answer the questions positively Source: 5-Diamond Patient Safety Program data collected online, Patient Safety Principles file/table, 2015; DFCompare 2015-1008 database. Notes: *Positive responses are “always” and “frequently.” Patient Safety Principles is a mandatory module. 22
Patient Safety Principles Module Slide 4.5: New Opportunities for Improvement, 2015
66% of facilities confirmed that new opportunities to improve patient safety were identified by their team during this module
Source: 5-Diamond Patient Safety Program data collected online, Patient Safety Principles file/table, 2015 Note: Patient Safety Principles is a mandatory module.
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Patient Safety Principles Module Chart 4.6: Best Practices Identification, 2015
When identifying best practices, facility staff emphasized:* 1. Safety 2. Communication 3. Patients 4. Staff 5. Errors 6. Importance 7. Care 8. Awareness 9. Improvement 10. Changes 11. Culture Source: 5-Diamond Patient Safety Program data collected online, Patient Safety Principles file/table, 2015 Notes: *Best practices key words are listed in descending order of number of references (#9-11 were equal). Patient Safety Principles is a mandatory module. The word cloud (picture) was made using wordclouds.com and Excel.
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Patient Safety Principles Module Chart 4.7: Need for Additional Resources, 2015 Other 3%
• Additional In-Service Training for Staff 43%
• Educational Materials for Patients 54%
Opportunity to provide additional training for staff Even greater opportunity to provide educational materials for patients
Source: 5-Diamond Patient Safety Program data collected online, Patient Safety Principles file/table, 2015 Notes: Patient Safety Principles is a mandatory module.
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Section 5: Thank You to Participants and Sponsors
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Thank You to Participants and Sponsors
THANK YOU • •
Thank you to participating dialysis facilities, Networks and sponsors for your commitment to patient safety To learn more about the 5-Diamond Patient Safety Program or to register as a participant visit 5diamondpatientsafety.org
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