9th Scope of Work (SOW) National Patient Safety Initiative (NPSI)

In our current 9th Scope Of Work with CMS, CFMC is working closely with Colorado hospitals and nursing homes to improve the quality of care through system and process changes in ten focused areas: surgical care, heart failure, methicillin-resistant staphylococcus aureus, pressure ulcers, physical restraints, the Health Care Leadership and Quality Assessment Tool, the AHRQ Culture Survey, drug safety, and public reporting.

The surgical care improvement project focuses on reducing pre-operative complications for surgical site infections, adverse cardiac events, venous thromboembolism and post-operative pneumonia. Participating hospitals will implement system changes to ensure improvements in care. These efforts overlap with the 5 Million Lives Campaign.

The heart failure project focuses on improvement of ACE-I and ARB use in hospitalized patients. In addition to focusing on ACE-I and ARB’s CFMC will provide hospitals with a composite score as a way to provide the right care for patients every time. This project overlaps with 5 Million Lives Campaign and Get With The Guidelines project.

MRSA is a new focus area for QIOs in the 9th SOW. However, many hospitals are currently improving systems through the 5 Million Lives project, and CFMC will build upon these existing efforts. Emphasis is currently being placed on hand-hygiene, environmental services, active surveillance cultures, contact precautions, and compliance with central line and ventilator bundles.

Pressure ulcer care improvements are focused on identifying the essential elements of pressure ulcer prevention and treatment: conducting a pressure ulcer assessment on admission, use of a valid and reliable pressure ulcer risk assessment instrument, and daily skin inspections. Another major area of focus is improving collaboration between hospitals and nursing homes. The 5 Million Lives Campaign is also working on similar pressure ulcer improvements.

Improvements related to physical restraints are focused on nursing home leadership’s commitment to restraint reduction or zero restraint use unless medically necessary and alternative interventions for conditions that are commonly associated with restraint use. Training on proper MDS coding will be offered through the CDPHE MDS & Automation Coordinators. These activities will include person-centered approaches and will utilize cooperative efforts between state partners.

Our leadership emphasis is a major component necessary for improving quality and patient safety. Through active involvement and buy-in from boards of directors and senior leadership from hospitals and nursing homes, we can help ensure quality and patient safety goals and compensation are aligned. Educational efforts are focused on individual hospital needs as identified through a CMS, IHI, and American Hospital Association collaborative tool.

AHRQ’s Organizational Safety Culture Survey helps hospitals and nursing homes to determine the greatest areas of need for promotion of patient safety activities.

CFMC’s also provides assistance with quality improvement efforts related to drug safety and the use of potentially inappropriate medications and drug-on-drug interactions. Tools and literature will be readily available to providers on our website (www.cfmc.org) and through our project collaborators.

• CFMC Patient Safety Fact Sheet
• CMS Patient Safety Fact Sheet

Contact Information

• Laura Palmer, Director of Performance Excellence, lpalmer@coqio.sdps.org
• Michelle Mills, Patient Safety Project Director, mmills@coqio.sdps.org
• Shari Ward, Patient Safety Interventionist, sward@coqio.sdps.org
• Judy Fye, Patient Safety Interventionist, jfye@coqio.sdps.org
• Richard Delaney, Organization Development Leader, rdelaney@coqio.sdps.org
• Marcy Cameron, Project Assistant, mcameron@coqio.sdps.org
• Laura Mankin, Project Assistant, lmankin@coqio.sdps.org