Hospital Safety Portal

How to use Safety Culture Improvement Tools

There is no safety in numbers, or in anything else. (James Thurber)

① Safety Culture

The self-assessment tool from "Blueprint for Success" (pp.33~40) is administered each year to a team which includes key executives, clinical leadership, patient safety leadership, and a patient and family representative. Each team member completes this self-assessment independently. The online software scores each category as a team, and the organizational scores and comments are shown here.

The "Patient Safety Culture Improvement Tool (PSCIT)" was developed to assist healthcare organizations in identifying actions to improve their culture.The tool is based on a safety culture maturity model, which describes five stages of cultural evolution, from pathological to generative.This guide explains how to interpret the graphic model that this website uses to display the results of data entry into this tool.

② Long-Term Care

The Nursing Home Quality Initiative (NHQI) website [1] provides information and resources about the Minimum Data Set (MDS), Care Compare, payment, quality measures, and survey and certification information for providers This website provides information about quality measures that are shown on the Care Compare website, which allows consumers, providers, states, and researchers to compare information on nursing homes.

Short Stay Quality Measures [ 1 ]

  1. Percent of Short-Stay Residents Who Were Re-Hospitalized after a Nursing Home Admission
  2. Percent of Short-Stay Residents Who Have Had an Outpatient Emergency Department Visit
  3. Percent of Residents Who Newly Received an Antipsychotic Medication
  4. Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury
  5. Percent of Residents Who Made Improvements in Function
  6. Percent of Residents Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
  7. Percent of Residents Who Received the Seasonal Influenza Vaccine*
  8. Percent of Residents Who Were Offered and Declined the Seasonal Influenza Vaccine*
  9. Percent of Residents Who Did Not Receive, Due to Medical Contraindication, the Seasonal Influenza Vaccine*
  10. Percent of Residents Who Were Assessed and Appropriately Given the Pneumococcal Vaccine
  11. Percent of Residents Who Received the Pneumococcal Vaccine*
  12. Percent of Residents Who Were Offered and Declined the Pneumococcal Vaccine*
  13. Percent of Residents Who Did Not Receive, Due to Medical Contraindication, the Pneumococcal Vaccine*

Long Stay Quality Measures [ 1 ]

  1. Number of Hospitalizations per 1,000 Long-Stay Resident Days
  2. Number of Outpatient Emergency Department Visits per 1,000 Long-Stay Resident Days
  3. Percent of Residents Who Received an Antipsychotic Medication
  4. Percent of Residents Experiencing One or More Falls with Major Injury
  5. Percent of High-Risk Residents with Pressure Ulcers
  6. Percent of Residents with a Urinary Tract Infection
  7. Percent of Residents who Have or Had a Catheter Inserted and Left in Their Bladder
  8. Percent of Residents Whose Ability to Move Independently Worsened
  9. Percent of Residents Whose Need for Help with Activities of Daily Living Has Increased
  10. Percent of Residents Assessed and Appropriately Given the Seasonal Influenza Vaccine
  11. Percent of Residents Who Received the Seasonal Influenza Vaccine*
  12. Percent of Residents Who Were Offered and Declined the Seasonal Influenza Vaccine*
  13. Percent of Residents Who Did Not Receive, Due to Medical Contraindication, the Seasonal Influenza Vaccine*
  14. Percent of Residents Assessed and Appropriately Given the Pneumococcal Vaccine
  15. Percent of Residents Who Received the Pneumococcal Vaccine*
  16. Percent of Residents Who Were Offered and Declined the Pneumococcal Vaccine*
  17. Percent of Residents Who Did Not Receive, Due to Medical Contraindication, the Pneumococcal Vaccine*
  18. Percent of Residents Who Were Physically Restrained
  19. Percent of Low-Risk Residents Who Lose Control of Their Bowels or Bladder
  20. Percent of Residents Who Lose Too Much Weight
  21. Percent of Residents Who Have Symptoms of Depression
  22. Percent of Residents Who Used Antianxiety or Hypnotic Medication

Dementia Management Quality Measures [ 2 ]

  1. Disclosure of dementia diagnosis
  2. Education and support of caregivers for patients with dementia
  3. Functional status assessment for patients with dementia
  4. Screening and managemnet of behavioral and psychiatric symptoms associated with dementia
  5. Safety concern screening and follow-up for patients with dementia
  6. Driving screening and follow-up for paitents with dementia
  7. Advance care planning and palliative care counseling for patients with dementia
  8. Pain assessment and follow-up for patients with dementia
  9. Pharmacological treatment of dementia

Quality Monitoring of Long-Term Care in Taiwan [ 3 ]

Nutrition
1.Unplanned weight loss
2.Prevalence of underweight institution residents
Falls
1.Recorded falls
2.Ratio of falls that caused injury
3.Falls that resulted in minor injury
4.Falls that resulted in moderate injury
5.Falls that resulted in severe injury
6.Falls that resulted in death
7.Rate of repeat falls
Pressure Ulcers
1.Prevalence of pressure ulcers
2.Prevalence of Stage 1 Pressure Ulcers
3.Prevalence of Stage II Pressure Ulcers
4.Prevalence of stage III Pressure Ulcers
5.Prevalence of Stage IV Pressure Ulcers
6.Prevalence of ungraded pressure ulcers [added in 2013]
7.Prevalence of pressure ulcers with suspected deep tissue injury [added in 2013]
8.Percentage of residents with existing pressure ulcers
9.Incidence of pressure ulcers
Physical Restraints
1.Rate of use of physical restraint
2.Rate of use of physical restraint for fall prevention
3.Rate of use of physical restraint for assisted therapy
4.Rate of use of physical restraint for other factors
5.Rate of use of repeated physical restraint
Catheter Usage
1.Prevalence of nasogastric tube use
2.Prevalence of indwelling urinary catheter use
3.Prevalence of tracheostomy use
4.Nasogastric tube removal rate
5.Indwelling urinary catheter removal rate
6.Tracheostomy tube removal rate
7.Unplanned extubation rate of nasogastric tube
8.Unplanned extubation rate of indwelling urinary catheter
9.Unplanned extubation rate of tracheostomy tube
Infection
1.Lower respiratory tract infections that received treatment
2.Resident/Patient Patient Days with Treated Lower Respiratory Tract Infection
3.Symptomatic urinary tract infections that received treatment
4.Symptomatic UTI with an indwelling urinary catheter that received treatment
5.Symptomatic UTI without an indwelling urinary catheter that received treatment
Discharge/Transfer for Admission to Acute Hospital
1.Unplanned transfer/discharge to acute inpatient care within 48 hours of admission
2.Unplanned transfer/discharge to acute inpatient care
3.Unplanned transfer/discharge to acute inpatient care due to cardiovascular hypocompensation
4.Unplanned transfer/discharge to acute inpatient care for fracture treatment or evaluation
5.Unplanned transfer/discharge to acute inpatient care due to gastrointestinal bleeding
6.Unplanned transfer/discharge to acute inpatient care due to infection
7.Unplanned transfer/discharge to acute inpatient care due to respiratory distress
8.Unplanned transfer/discharge to acute inpatient care for other medical or surgical reasons
Pharmacological Usage
1.Use of long-acting sedatives
2.Continuous use of long-acting sedatives
3.Oral antibiotic drug use
4.Continuous use of oral antibiotics
5.Oral short-acting nonsteroidal pain medication use rate
6.Continuous use of oral short-acting nonsteroidal pain medications
7.Oral Warfarin Anticoagulant Drug Clotting Time (INR) Monitoring
8.Oral Digoxin Digitalis Drug Serum Digitalis Drug Concentration Monitoring
9.Polypharmacy (≥9 items) use rate
Daily Activities
Daily life functions progress

References:

  1. Centers for Medicare & Medicaid Services Quality measures cms.gov/Medicare/ Accessed: August 5, 2022.
  2. Unwin BK, Loskutova N, Knicely P, Wood CD. Quality measures and clinical tools can bring focus and clarity to caring for patients with cognitive impairment and supporting their caregivers. aafp.org/pubs/fpm/ Fam Pract Manag. 2019;26(1):11-16
  3. 衛生福利部107年度護理及健康照護司 (Ministry of Health and Welfare 107 Nursing and Health Care Division) 照護品質指標監測及持續改進 指引簡易手冊 (Nursing Care Quality Indicator Monitoring and Continuous Improvement Guidelines Simple Manual) www.mohw.gov.tw (pp.5-6) October 7, 2019.