5 Diamond Data Review 2014 - 5 Diamond Patient Safety Program [PDF]

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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

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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%

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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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