Safety Teams and Organizational Structure
    Access to Information
    Facility Expectations
    Engagement of Patient/Client/Resident and Family


Key Item

Road Map to a Comprehensive Healthcare-Associated Infection (HAI) Prevention Program. See the SAFE section. Complete the HAI road map audit checklist prior to beginning any of the gap analyses.

Organizational Culture/SAFE

Successfully implementing and sustaining best practices related to any patient safety or quality topic involve building a strong foundation and culture to support the practices. The work of CHAIN incorporates this aspect of addressing healthcare-associated infection (HAI) prevention through a number of avenues:

  • SAFE practices from the HAI Road Map guide organizations in developing the infrastructure necessary to support and sustain infection prevention best practices, e.g., interdisciplinary teams, sharing data across the organization, and clarifying roles and expectations.
  • SAFE practices incorporate best practices for creating a patient safety culture that is vital for successfully implementing and sustaining infection prevention practices. Practices included in the HAI Road Map align with strategies promoted by the Minnesota Alliance for Patient Safety (MAPS) through its safety culture work and The Comprehensive Unit-Based Safety Program (CUSP). CUSP is a safety culture program designed to educate and improve awareness about patient safety and quality of care, empower staff to take charge and improve safety in the workplace, create partnerships between units and hospital executives to improve organizational culture, and provide resources for unit improvement efforts and tools to investigate and learn from defects.

SAFE: Tools to Support an Organizational Culture that Reduces Healthcare-associated Infections

Safety Teams and Organizational Structure

Bill Ward’s HAI Surveillance Calculator for the HAI Business Case. A helpful tool for calculating HAI costs when discussing the business case for HAI prevention. (27-min audio)

MAPS Just Culture Toolkit (Planning Phase, Early Implementation Phase, Making Good Progress Phase). A toolkit produced by the Minnesota Alliance for Patient Safety (MAPS) to help health care providers create a learning, just, and  accountable culture. (22-page PDF)

Solicit patient/resident/client & family input

Executive Review of Improvement Projects Meeting Tool. An outline for conducting a executive project review, including whether the project is on track, barriers to progress, team guidance, budget, return on investment, and return on aims. (2-page PDF)

The Guide for Developing a Community-Based Patient Safety Advisory Council, from the Agency for Healthcare Research and Quality, provides information and guidance to empower individuals and organizations to develop a community-based advisory council. These councils involve patients, consumers, and a variety of practitioners and professionals from health care and community organizations to drive change for patient safety through education, collaboration, and consumer engagement. (60-page PDF) 

Model for Improvement Map. Steps for implementing improvement, using the Plan Do Study Act model and asking the following questions: What are we trying to accomplish? How will we know a change is an improvement? What changes can we make that will result in an improvement? Produced by HealthEast Care System. (1-page PDF)

Partnering with Patients and Families to Enhance Safety and Quality: A Mini Toolkit. Produced by the Institute for Patient- and Family-Centered Care, Bethesda, MD. (26-page PDF) 

Patient and Family Advisory Councils: A Checklist for Getting Started. Produced by the Institute for Patient- and Family-Centered Care, Bethesda, MD. (1-page PDF) 

Patient and Family Advisory resources. Resources from the Dana Farber Cancer Institute to help you get started improving communication and involving patients and their families in decision-making. Viewed 08/23/12

Patient Safety Councils: A New Tool for Patient Safety. An article by Carolyn M. Clancy, MD, Director of the Agency for Healthcare Research and Quality, on how to create your own patient safety advisory council. Patient Safety and Quality Healthcare, viewed 08/23/12

Project Roles, October 7, 2007. An outline of the roles and responsibilities of project team members. Produced by HealthEast Care System, adapted from the Institute for Healthcare Improvement definitions. (2-page PDF)

Access to Information

HAI Criteria Checklist. A checklist of criteria by the Tennessee Department of Health. The checklist is used to assist in defining HAI, and is helpful in working through definitions in a standardized way. Go to the bottom of the page and click “Checklists for HAI definitions (ZIP).

Infection Prevention and Control Risk Assessment 2012. A sample form used to update risks or develop an annual infection control plan. Consideration is given to issues that are high risk, high volume, or problem prone, as well as to new procedures and techniques, emerging or reemerging trends, changes in regulatory requirements, patient and worker safety initiatives, and other evidence-based recommendations. Produced by HealthEast Care System, St. Joseph's Hospital. (5-page Word doc)

MAPS Just Culture Toolkit : "Making Good Progress Phase" tools. Read the The Making Good Progress Phase section of the toolkit produced by the Minnesota Alliance for Patient Safety (MAPS) to help health care providers create a learning, just, and  accountable culture. (22-page PDF)

Navigating NHSN Surgical Site Infection (SSI) Surveillance. A PowerPoint presentation with case studies by Gloria C. Morrell, nurse consultant, National Healthcare Safety Network. (121-page PDF)

What you need to know: NHSN data audits and more. An interview with Mary Andrus of APIC Consulting, APIC publication: Prevention Strategist, Spring 2013, pages 48-50.

Facility Expectations

Disclosure Resources. Guidelines from The Doctors Company to help health care professionals improve their effectiveness when disclosing adverse events and complications. Supports the American Medical Association’s ethical requirement to inform the patient of all the facts necessary to ensure an understanding of what occurred. Includes a list of state disclosure laws. Viewed 08/23/12.

Disclosure of Unanticipated Outcomes, article from ECRI Institute, January 2008, with a discussion of disclosure policies, regulations and standards, incident reporting, risk management attitudes, who is responsible, cultural issues, and more. (21-page PDF) 

Example of "Stop the Line" policy. Article about Barnes Jewish Hospital’s policy to support a just culture in which physicians and staff can communicate freely in support of patient safety, and to take action, if necessary, with other team members when patient safety may be at risk. Washington University of St. Louis School of Medicine, viewed 08/23/12.

Full Disclosure and Apology—An Idea Whose Time has Come, article by Lucian L. Leape, MD, professor of health policy at Harvard University and long-time advocate of the nonpunitive systems approach to the prevention of medical errors. The Physician Executive April-March 2006. (3-page PDF)

Patient Safety Initiative Pilot Phase – Revised Draft Surveyor Worksheets. The Centers for Medicare & Medicaid Services is testing three revised surveyor worksheets for assessing compliance with three hospital Conditions of Participation (CoPs): Quality Assessment and Performance Improvement, Infection Control, and Discharge Planning. It is focusing on compliance with these CoPs as a means to reduce hospital-acquired conditions, including healthcare associated infections, and preventable readmissions. May 18, 2012 (88-page PDF)

Sample hospital policies on disclosure. Policies shared by various hospitals and a 3-part series from the American Society for Health Risk Management, Premier, Inc., viewed 08/23/12.

When Things Go Wrong - Responding to Adverse Events, a consensus statement of Harvard Hospitals, Burlington, Massachusetts Coalition for the Prevention of Medical Errors, 2006. (42-page PDF) 

Engagement of Patient/Client/Resident and Family

Supports patient/resident/client understanding of health care information

Culture Care Connection website. Culture Care Connection is an online learning and resource center, developed by Stratis Health and funded by UCare. The site is aimed at supporting health care providers, staff, and administrators in their ongoing efforts to provide culturally-competent care in Minnesota. Cultural competence is defined by Office of Minority Health as having the capacity to function effectively within the context of the cultural beliefs, behaviors, and needs of consumers and their communities. Viewed 08/26/12.

Culture, Language and Health Literacy. Tools from the Health Resources and Services Administration to help health care providers recognize and address the unique culture, language and health literacy of diverse consumers and communities. Viewed 08/26/12.

Health Literacy Universal Precautions Toolkit. An Agency for Health Research and Quality toolkit that offers primary care practices a way to assess their services for health literacy considerations, raise awareness of the entire staff, and work on specific areas.

Minnesota Health Literacy Partnership Teach-back guide. This guide is designed to help facilitate trainings and discussions  using the teach-back method. Materials include a teach-back video, PowerPoint presentation, discussion ideas, and activities that can be used to enhance program effectiveness.

Empower patients, residents, clients, and families to be informed and voice their concerns

Center for Shared Decision Making provides materials and resources to encourage physicians and patients to make decisions together, including a decision aid library with a guide, DVDs, and booklets. Viewed 08/26/12.

Improving Patient Safety and Satisfaction via Patient Portals. An article from the American Association for Clinical Chemistry on providing patients with access to their own electronic medical records via the Internet to ultimately improve patient safety. Viewed 08/25/12

Informed Medical Decision Making Foundation provides clinical models and patient decision aids to foster informed patient and physician decision making. Viewed 08/26/12.

Measuring the Impact of Patient Portals - What the Literature Tells Us, from the California Healthcare Foundation, May 2011. This report examines published peer reviewed studies and other research documenting the implementation of patient portals and their impact on health care delivery. 

Model “stop the line” policy from the Minnesota Hospital Association outlines the responsibility and authority of all hospital employees, medical staff, students and volunteers to immediately intervene to protect the safety of a patient.

Model “stop the line” policy from the University of Michigan Health System outlining the obligation of all staff, students, and volunteers to speak up to identify real or perceived safety concerns, uncomfortable situations, or confusion about care provided. 

NPSF Fact Sheets and Guidelines for Patients and Consumers. The National Patient Safety Foundation provides tools and resources patients can use when they see a health care provider or when they are admitted to the hospital for care. Viewed 0826/12

Speak Up materials. Provided by the Joint Commission, including Speak Up: Five Things You Can Do To Prevent Infection brochures available in English and Spanish. Viewed 08/26/12

Tools to Support an Organizational Culture that Reduces HAIs

AHRQ Patient Safety Culture Survey. Safety culture surveys are useful for measuring organizational conditions that can lead to adverse events and patient harm in health care organizations. Organizations that want to assess their existing culture of patient safety should consider conducting a safety culture survey. Agency for Healthcare Research and Quality suggests using safety culture surveys to:

  • Raise staff awareness about patient safety.
  • Diagnose and assess the current status of patient safety culture.
  • Identify strengths and areas for patient safety culture improvement.
  • Examine trends in patient safety culture change over time.
  • Evaluate the cultural impact of patient safety initiatives and interventions.
  • Conduct internal and external comparisons.

Three of patient safety culture assessment tools for hospitals, nursing homes, and ambulatory outpatient medical offices.

Comprehensive Unit-Based Safety Program (CUSP). CUSP is a structured strategic framework for safety improvement that integrates communication, teamwork, and leadership to create and support a culture of patient safety that can prevent harms. The program features: evidence-based safety practices, staff training tools, standards for consistently measuring infection rates, engagement of leadership, and tools to improve teamwork among doctors, nurses, and other members of the health care team.

Equip frontline providers with the tools, metrics, and framework to tackle the challenges of quality improvement using the five steps from CUSP:

  1. Staff are educated on the science of safety.
  2. Staff complete an assessment of patient safety culture.
  3. A senior hospital executive partners with the unit to improve communications and educate leadership.
  4. Staff learn from unit defects.
  5. Staff use tools, including checklists, to improve teamwork, communication, and other systems of work.

eCUSP. This a web-based program allowing health care organizations to manage, monitor, record and share all their improvement work. It can also provide a mechanism for CUSP to be well-organized and monitored, while providing the impetus for identifying and managing safety and quality initiatives, and sharing work within a hospital system or throughout the entire health care industry. This program provides an avenue of open communication for all staff from senior executives to unit clerks.

Interpreting Safety Culture Survey Results and Action Planning. Presented by Katherine Jones, PT, PhD, University of Nebraska Medical Center. (90-minute webinar, recorded June 2011)

Partnering to Heal Video-Simulation Training Program. U.S. Department of Health & Human Services Office of the Assistant Secretary for Health (ASH)-produced computer-based, video-simulation training program on infection control practices for clinicians, health professional students, and patient advocates. The training highlights effective communication about infection control practices and ideas for creating a "culture of safety" in healthcare institutions to keep patients from getting sicker. Users assume the identity of the five main characters and make decisions about preventing healthcare-associated infections (HAIs).

Success Stories

Unit-Based Safety Program Improves Safety Culture, Reduces Medication Errors and Length of Stay. A pre- and post-implementation evaluation of CUSP in two surgical intensive care units at Johns Hopkins Hospital found that the program improved the safety culture and was associated with a reduction in intensive care length of stay, medication errors, and possibly nursing turnover. Similar results are seen in other units and other settings (e.g., Michigan intensive care units).

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CHAIN is an effort lead by the Association for Professionals in Infection Control and Epidemiology-Minnesota (APIC MN), Minnesota Department of Health, Minnesota Hospital Association, and Stratis Health, which represents Lake Superior Quality Innovation Network in Minnesota.