1 © 2007 tmit children hospitals - confidential do not distribute task force submitters lfg...
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1© 2007 TMIT Children Hospitals - Confidential Do Not Distribute
Task Force Submitters Task Force Submitters LFG AnalysisLFG Analysis
Task Force Submitters Task Force Submitters LFG AnalysisLFG Analysis
Children’s Hospitals TaskforceChildren’s Hospitals TaskforceOctober 2007October 2007
Children’s Hospitals TaskforceChildren’s Hospitals TaskforceOctober 2007October 2007
2© 2007 TMIT Children Hospitals - Confidential Do Not Distribute
ObjectiveObjectiveObjectiveObjective
• Provide Snapshot of Children’s Provide Snapshot of Children’s Hospital vs. National ResultsHospital vs. National Results
• Identify Gaps and Obtain FeedbackIdentify Gaps and Obtain Feedback
• Provide Context for Adoption Simulator Provide Context for Adoption Simulator SubmissionSubmission
• Provide Snapshot of Children’s Provide Snapshot of Children’s Hospital vs. National ResultsHospital vs. National Results
• Identify Gaps and Obtain FeedbackIdentify Gaps and Obtain Feedback
• Provide Context for Adoption Simulator Provide Context for Adoption Simulator SubmissionSubmission
3© 2007 TMIT Children Hospitals - Confidential Do Not Distribute
Summary of FindingsSummary of FindingsSummary of FindingsSummary of Findings
• 10 Organizations Submitted to the TMIT 10 Organizations Submitted to the TMIT SurveySurvey
• Average Average 721721 Points out of 1,000 Points out of 1,000
• National Average isNational Average is 706 706
• Range 918 – 492 PointsRange 918 – 492 Points
• 10 Organizations Submitted to the TMIT 10 Organizations Submitted to the TMIT SurveySurvey
• Average Average 721721 Points out of 1,000 Points out of 1,000
• National Average isNational Average is 706 706
• Range 918 – 492 PointsRange 918 – 492 Points
4© 2007 TMIT Children Hospitals - Confidential Do Not Distribute
Distribution of SampleDistribution of SampleDistribution of SampleDistribution of Sample
0
1
2
3
4
5
n
Survey Score
5© 2007 TMIT Children Hospitals - Confidential Do Not Distribute
Summary of FindingsSummary of FindingsSummary of FindingsSummary of Findings
• Strengths:Strengths:– ““As” Action (“Strongest” of the 4 As)As” Action (“Strongest” of the 4 As)– Safe Practices (Above National Average)Safe Practices (Above National Average)
• SP# 1.1 – Culture of Safety (+11%)SP# 1.1 – Culture of Safety (+11%)• SP# 2 – Informed Consent (+12%)SP# 2 – Informed Consent (+12%)• SP# 4 – Disclosure (+17%)SP# 4 – Disclosure (+17%)• SP# 17 – Perioperative Myocardial Ischemia SP# 17 – Perioperative Myocardial Ischemia
Prevention (+11%)Prevention (+11%)• SP# 20 – BSI (+16%)SP# 20 – BSI (+16%)• SP# 22 – Hand Hygiene (+13%)SP# 22 – Hand Hygiene (+13%)• SP# 25 – Wrong-Site (+17%)SP# 25 – Wrong-Site (+17%)
• Strengths:Strengths:– ““As” Action (“Strongest” of the 4 As)As” Action (“Strongest” of the 4 As)– Safe Practices (Above National Average)Safe Practices (Above National Average)
• SP# 1.1 – Culture of Safety (+11%)SP# 1.1 – Culture of Safety (+11%)• SP# 2 – Informed Consent (+12%)SP# 2 – Informed Consent (+12%)• SP# 4 – Disclosure (+17%)SP# 4 – Disclosure (+17%)• SP# 17 – Perioperative Myocardial Ischemia SP# 17 – Perioperative Myocardial Ischemia
Prevention (+11%)Prevention (+11%)• SP# 20 – BSI (+16%)SP# 20 – BSI (+16%)• SP# 22 – Hand Hygiene (+13%)SP# 22 – Hand Hygiene (+13%)• SP# 25 – Wrong-Site (+17%)SP# 25 – Wrong-Site (+17%)
6© 2007 TMIT Children Hospitals - Confidential Do Not Distribute
Summary of FindingsSummary of FindingsSummary of FindingsSummary of Findings
• Gaps were Identified:Gaps were Identified:– ““As” Accountability (Weakest of the 4 As)As” Accountability (Weakest of the 4 As)– Safe Practices (below National Average)Safe Practices (below National Average)
• SP# 15 – Pharmacists’ Role (-6%)SP# 15 – Pharmacists’ Role (-6%)• SP# 19 – Risk of Aspiration (-8%)SP# 19 – Risk of Aspiration (-8%)• SP# 26 – Perioperative Myocardial Ischemia SP# 26 – Perioperative Myocardial Ischemia
Prevention (-36%)Prevention (-36%)• SP# 28 – DVT/VTE Prevention (-31%)SP# 28 – DVT/VTE Prevention (-31%)• SP# 29 – Anticoagulation Therapy (-17%)SP# 29 – Anticoagulation Therapy (-17%)
• Gaps were Identified:Gaps were Identified:– ““As” Accountability (Weakest of the 4 As)As” Accountability (Weakest of the 4 As)– Safe Practices (below National Average)Safe Practices (below National Average)
• SP# 15 – Pharmacists’ Role (-6%)SP# 15 – Pharmacists’ Role (-6%)• SP# 19 – Risk of Aspiration (-8%)SP# 19 – Risk of Aspiration (-8%)• SP# 26 – Perioperative Myocardial Ischemia SP# 26 – Perioperative Myocardial Ischemia
Prevention (-36%)Prevention (-36%)• SP# 28 – DVT/VTE Prevention (-31%)SP# 28 – DVT/VTE Prevention (-31%)• SP# 29 – Anticoagulation Therapy (-17%)SP# 29 – Anticoagulation Therapy (-17%)
© 2007 TMIT 7Children Hospitals - Confidential Do Not Distribute
Culture of Safety: Practice 1 Element 1 – 120 Points
73%
62%
0
10
20
30
40
50
60
70
80
90
100
Children’s Hospitals
62% Nat’l. Avg.
National Average
© 2007 TMIT 8Children Hospitals - Confidential Do Not Distribute
67% 68%
0
10
20
30
40
50
60
70
80
90
100
62% Natl. Avg.
Culture of Safety: Practice 1 Element 2 – 20 Points
68% Nat’l. Avg.
Children’s Hospitals National Average
© 2007 TMIT 9Children Hospitals - Confidential Do Not Distribute
58% 58%
0
10
20
30
40
50
60
70
80
90
100
62% Natl. Avg.
Culture of Safety: Practice 1 Element 3 – 40 Points
58% Nat’l. Avg.
Children’s Hospitals National Average
© 2007 TMIT 10Children Hospitals - Confidential Do Not Distribute
74% 73%
0
10
20
30
40
50
60
70
80
90
100
Culture of Safety: Practice 1 Element 4 – 120 Points
73% Nat’l. Avg.
Children’s Hospitals National Average
© 2007 TMIT 11Children Hospitals - Confidential Do Not Distribute
59%
47%
0
10
20
30
40
50
60
70
80
90
100
62% Natl. Avg.
Informed Consent: Practice 2 – 4 Points
47% Nat’l. Avg.
Children’s Hospitals National Average
© 2007 TMIT 12Children Hospitals - Confidential Do Not Distribute
58%
51%
0
10
20
30
40
50
60
70
80
90
100
62% Natl. Avg.
Life-Sustaining Treatment: Practice 3 – 4 Points
51% Nat’l. Avg.
Children’s Hospitals National Average
© 2007 TMIT 13Children Hospitals - Confidential Do Not Distribute
85%
68%
0
10
20
30
40
50
60
70
80
90
100
62% Natl. Avg.
Disclosure: Practice 4 – 25 Points
68% Nat’l. Avg.
Children’s Hospitals National Average
© 2007 TMIT 14Children Hospitals - Confidential Do Not Distribute
75% 78%
0
10
20
30
40
50
60
70
80
90
100
62% Natl. Avg.
Nursing Workforce: Practice 5 – 100 Points
78% Nat’l. Avg.
Children’s Hospitals National Average
© 2007 TMIT 15Children Hospitals - Confidential Do Not Distribute
66%63%
0
10
20
30
40
50
60
70
80
90
100
62% Natl Avg.
Direct Caregivers Workforce: Practice 6 – 20 Points
63% Nat’l. Avg.
Children’s Hospitals National Average
© 2007 TMIT 16Children Hospitals - Confidential Do Not Distribute
75%
69%
0
10
20
30
40
50
60
70
80
90
100
62% Natl. Avg.
Critical Care Information: Practice 8 – 84 Points
69% Nat’l. Avg.
Children’s Hospitals National Average
© 2007 TMIT 17Children Hospitals - Confidential Do Not Distribute
71% 73%
0
10
20
30
40
50
60
70
80
90
100
Order Read-back: Practice 9 – 25 Points
73% Nat’l. Avg.
Children’s Hospitals National Average
© 2007 TMIT 18Children Hospitals - Confidential Do Not Distribute
78%
70%
0
10
20
30
40
50
60
70
80
90
100
Labeling Studies: Practice 10 – 15 Points
70% Nat’l. Avg.
Children’s Hospitals National Average
© 2007 TMIT 19Children Hospitals - Confidential Do Not Distribute
75%69%
0
10
20
30
40
50
60
70
80
90
100
62% Natl. Avg.
Discharge System: Practice 11 – 25 Points
69% Nat’l. Avg.
Children’s Hospitals National Average
© 2007 TMIT 20Children Hospitals - Confidential Do Not Distribute
85%82%
0
10
20
30
40
50
60
70
80
90
100
62% Natl. Avg.
Abbreviations: Practice 13 – 11 Points
82% Nat’l. Avg.
Children’s Hospitals National Average
© 2007 TMIT 21Children Hospitals - Confidential Do Not Distribute
85% 83%
0
10
20
30
40
50
60
70
80
90
100
62% Natl. Avg.
Medication Reconciliation: Practice 14 – 35 Points
83% Nat’l. Avg.
Children’s Hospitals National Average
© 2007 TMIT 22Children Hospitals - Confidential Do Not Distribute
74%
81%
0
10
20
30
40
50
60
70
80
90
100
62% Natl. Avg.
Pharmacists’ Role: Practice 15 – 32 Points
81% Nat’l. Avg.
Children’s Hospitals National Average
© 2007 TMIT 23Children Hospitals - Confidential Do Not Distribute
74%71%
0
10
20
30
40
50
60
70
80
90
100
62% Natl. Avg.
Standardized Medication Labeling & Packaging: Practice 16 – 20 Points
71% Nat’l. Avg.
Children’s Hospitals National Average
© 2007 TMIT 24Children Hospitals - Confidential Do Not Distribute
84%
73%
0
10
20
30
40
50
60
70
80
90
100
62% Natl. Avg.
High-Alert Medications: Practice 17 – 20 Points
73% Nat’l. Avg.
Children’s Hospitals National Average
© 2007 TMIT 25Children Hospitals - Confidential Do Not Distribute
62%
68%
0
10
20
30
40
50
60
70
80
90
100
62% Natl. Avg.
Unit-Dose Medications: Practice 18 – 25 Points
68% Nat’l. Avg.
Children’s Hospitals National Average
© 2007 TMIT 26Children Hospitals - Confidential Do Not Distribute
74%
82%
0
10
20
30
40
50
60
70
80
90
100
62% Natl. Avg.
Risk of Aspiration & VAP Prevention: Practice 19 – 20 Points
82% Nat’l. Avg.
Children’s Hospitals National Average
© 2007 TMIT 27Children Hospitals - Confidential Do Not Distribute
95%
80%
0
10
20
30
40
50
60
70
80
90
100
62% Natl. Avg.
Central Venous Catheter Blood Stream Infection Prevention: Practice 20 – 30 Points
80% Nat’l. Avg.
Children’s Hospitals National Average
© 2007 TMIT 28Children Hospitals - Confidential Do Not Distribute
84%
0
10
20
30
40
50
60
70
80
90
100
62% Natl. Avg.
Surgical-Site Infection: Practice 21 – 30 Points
84% Nat’l. Avg.
Children’s Hospitals
79%
National Average
© 2007 TMIT 29Children Hospitals - Confidential Do Not Distribute
81%
0
10
20
30
40
50
60
70
80
90
100
62% Natl. Avg.
Hand Hygiene: Practice 22 – 30 Points
81% Nat’l. Avg.
Children’s Hospitals
94%
National Average
© 2007 TMIT 30Children Hospitals - Confidential Do Not Distribute
82%
76%
0
10
20
30
40
50
60
70
80
90
100
Influenza Protection: Practice 23 – 10 Points
76% Nat’l. Avg.
Children’s Hospitals National Average
© 2007 TMIT 31Children Hospitals - Confidential Do Not Distribute
83%
0
10
20
30
40
50
60
70
80
90
100
62% Natl. Avg.
Wrong-site Surgical Prevention: Practice 25 – 20 Points
83% Nat’l. Avg.
Children’s Hospitals
100%
National Average
© 2007 TMIT 32Children Hospitals - Confidential Do Not Distribute
51%
0
10
20
30
40
50
60
70
80
90
100
62% Natl. Avg.
Perioperative Myocardial Ischemia/Infarct Prevention: Practice 26 – 20 Points
51% Nat’l. Avg.
0%
Children’s Hospitals
15%
National Average
© 2007 TMIT 33Children Hospitals - Confidential Do Not Distribute
77%
0
10
20
30
40
50
60
70
80
90
100
Pressure Ulcer Prevention: Practice 27 – 25 Points
77% Nat’l. Avg.
Children’s Hospitals
84%
National Average
© 2007 TMIT 34Children Hospitals - Confidential Do Not Distribute
63%
0
10
20
30
40
50
60
70
80
90
100
DVT/VTE Prevention: Practice 28 – 25 Points
63% Nat’l. Avg.
31%
Children’s Hospitals National Average
© 2007 TMIT 35Children Hospitals - Confidential Do Not Distribute
51%
0
10
20
30
40
50
60
70
80
90
100
62% Natl. Avg.
Anticoagulation Therapy: Practice 29 –– 35 Points
51% Nat’l. Avg.
Children’s Hospitals
34%
National Average
© 2007 TMIT 36Children Hospitals - Confidential Do Not Distribute
65%62%
0
10
20
30
40
50
60
70
80
90
100
62% Natl. Avg.62% Nat’l. Avg.
Contrast Media-induced Renal Failure: Practice 30 –– 10 Points
Children’s Hospitals National Average