Blake Medical Center
2020 Community Patient Safety Report
Highly reliable organizations have a culture and a system that are centered on keeping their patients safe. They are constantly alert for what could go wrong and they know what to do if things do go wrong. They work in teams, communicate effectively, and are not afraid to speak up. They hold themselves and each other accountable and make sure that they share important learning across the system. Highly reliable organizations are resilient.
Strides made to sustain a strong culture of safety and include the following initiatives and programs:
AHRQ - Patient safety culture survey
In 2020, we conducted the Agency for Healthcare Research and Quality’s (AHRQ) Survey on patient Safety Culture. This survey is designed to measure organizational learning, teamwork, communication, feedback about errors, non-punitive response, staffing, hospital management support, and hospital employee’s perceptions of safety, frequency of events reported, and gives an overall safety grade. Employees completed the survey with a response rate of 60%.
Actions progressing culture of safety:
- Aligned organizational goals – safety, hospitality, empathy, efficiency
- Department huddles and safety briefs
- Safety Huddles held daily
- Weekly safety rounds
- “Good Catch Award” recognizing staff for patient safety
- Handoff audits
- Leader rounding
- Serious event analyses with patient falls, hospital-acquired conditions
- Department monthly operating reviews
- Education of leaders and providers on risk reduction techniques, tools, near-miss reporting, and TeamSTEPPS
- Teamwork training included in new hire orientation
- Activation of safety committees
- Failure Mode Effect Analysis completed on an annual basis
- Implementation of Tools and Tactics to Improve Patient Safety with ongoing education for both leadership and staff
Infection prevention projects:
Continued focus on hand hygiene and the wearing of personal protection compliance. Root Cause Analyses are conducted on any hospital-acquired infection. Bathing with chlorhexidine was instituted for all patients with a central line and indwelling urinary catheters. A bladder management protocol is in place with a continued drive to increased utilization of external modalities to prevent possible catheter-associated infections.
Clinical excellence initiatives:
In 2018 focused efforts to reduce severe sepsis and septic shock mortality through the implementation of the following initiatives; scorecards with bundle compliance performance, use of the EV-1000, coding accuracy, and continued education of staff and providers. We continue to refine our SPOT monitoring tool that alerts the health care providers to changes in vital signs requiring an immediate reassessment of the patient and SEPSIS Alert if warranted.
We continue to improve our processes to get patients with hip fracture to the OR within the first 24 hours of admission. Evidence demonstrates that getting patients to surgery within 24 hours of arrival is associated with better functional outcomes and lower rates of perioperative complications. Our trauma team sees all patients with hip fractures and notifies the orthopedic surgeon and anesthesia to get the patient evaluated and on the surgery schedule to expedite the process.
The National Institute of Neurological Disorders and Stroke (NINDS) study suggested that 8 out of 18 stroke patients who receive Alteplase according to a strict protocol will recover by three months after the event without significant disability. Currently, 17.6% of our stroke patients are receiving Alteplase with a median door to needle time of 35 minutes from arrival to our Emergency Room. As of June 2020, Blake Medical Center is the only Certified Comprehensive Stroke Center in Manatee County through DNV (Det Norske Veritas). Additionally, Blake has the capability to provide all stroke care from arrival to our ED through our CARF certified inpatient rehabilitation unit.
- Reduce mortality index to at or below 0.71
- Decrease hospital-acquired infections to the 50th percentile NHSN Standardized Infection Ratio (SIR).
- Increase Sepsis/Septic Shock Bundle Compliance above 75%
- PCI for STEMI patients within 90 minutes 100%
- Reduce inpatient falls year over year by 10%. Goal 3.40 falls per 1000 patient days
- Improve top box scores – Inpatient from 63.5% to 69.7%, ER from 60.5% to 66.8%, OAS from 71.6% to 80.9%