Links - World Health Organization

African Partnerships for Patient Safety

Resource Map

Revised version 2 English February 2013

Note: The Resource Map will be undergoing a complete refresh and update during the first quarter of 2013. Please check the APPS website for news of the launch of version 3. In addition, the APPS Team will contact all members of the APPS network when version 3 is issued.

© World Health Organization 2013 The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The mention of specific resources does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use.

Note: inclusion of a resource does not imply endorsement by WHO of any specific organization associated with the resource.

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Contents Introduction

About the African Partnerships for Patient Safety Resource Map Structure and function of the APPS Resource Map Types of resources Use of case studies Developing Additional Case Studies for Future Learning How to share your case study Rationale for including a resource Inclusion criteria Future considerations Abbreviations

Level 1

The Action Area Matrix Introduction to the Action Area Matrix Action area 1: Patient safety and health services and systems improvement Action area 2: National Patient Safety Policy Action area 3: Knowledge and learning in patient safety Action area 4: Patient safety awareness raising Action area 5: Health care-associated infections Action area 6: Healthcare worker protection Action area 7: Healthcare waste management Action area 8: Safe surgical care Action area 9: Medication safety Action area 10: Patient safety partnerships Action area 11: Patient safety funding Action area 12: Patient safety surveillance and research

Level 2

Key information Action area 1: Patient safety and health services and systems improvement Action area 2: National Patient Safety Policy Action area 3: Knowledge and learning in patient safety


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Level 3

Action area 4: Patient safety awareness raising Action area 5: Health care-associated infections Action area 6: Healthcare worker protection Action area 7: Healthcare waste management Action area 8: Safe surgical care Action area 9: Medication safety Action area 10: Patient safety partnerships Action area 11: Patient safety funding Action area 12: Patient safety surveillance and research

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Case studies

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Action area 1: Patient safety and health services and systems improvement Action area 2: National Patient Safety Policy Action area 3: Knowledge and learning in patient safety Action area 4: Patient safety awareness raising Action area 5: Health care-associated infections Action area 6: Healthcare worker protection Action area 7: Healthcare waste management Action area 8: Safe surgical care Action area 9: Medication safety Action area 10: Patient safety partnerships Action area 11: Patient safety funding Action area 12: Patient safety surveillance and research


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Introduction About the African Partnerships for Patient Safety Resource Map: African Partnerships for Patient Safety (APPS) is a WHO programme seeking to build and strengthen partnerships between hospitals in Africa and Europe, focusing on patient safety. The APPS Resource Map has been co-developed with colleagues participating in APPS but is presented as a key resource for anyone interested in strengthening the safety and security of hospitals. The Resource Map is constructed around the 12 Patient Safety Action Areas proposed by WHO AFRO and endorsed by all 46 countries in WHO’s African Region (the same 12 Patient Safety Action Areas that form the basis of the APPS Situational Analysis). The Map was developed in response to the needs of the first wave of partnerships. The 12 Action Areas are: 1. Patient safety and health services and systems improvement: 2. National Patient Safety Policy: 3. Knowledge and learning in patient safety: 4. Patient safety awareness raising: 5. Health care-associated infections: 6. Healthcare worker protection: 7. Healthcare waste management 8. Safe surgical care: 9. Medication safety: 10. Patient safety partnerships: 11. Patient safety funding: 12. Patient safety surveillance and research

Overview of the Resource Map:  Designed to make it easy to find information on patient safety, partnership building and spread.  Three levels, starting with a simple list and culminating in real-life case studies describing the resource in-use.  Anyone using the resource can contribute to its future development by sharing their own case study of how useful the resource is in practice.


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Structure and function of the APPS Resource Map The Map is arranged across three levels. Each level builds on the former, providing increasing amounts of information on a particular resource. The structure is summarised in figure 1.

Figure 1: Quick-view of the Resource Map


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Types of resources The term resource is used to describe anything that might be useful in addressing the gaps identified as a result of undertaking the APPS Situational Analysis. The resources listed within this Map are diverse and span, not exclusively, guidance, policies, publications, templates, toolkits and reports and reflections from hospitals that have implemented patient safety improvements using the APPS Approach.

Use of Case Studies Level 3 of the APPS Resource Map presents case studies illustrating examples of how a particular resource has been applied in a health care context. The case studies provide practical examples associated with using a resource across different organizations, countries and regions. The case studies included are intended to be helpful in considering utility of a resource. In addition, version 3 of the Resource Map – currently under construction will contain reference to APPS presentations and webinars, and a synthesis of visit reports from APPS First and Second Wave Partners.

Developing Additional Case Studies for Future Learning Anyone using this Resource Map is actively invited to share information on their experience. This will contribute to continuous improvement to the Resource Map that helps partnerships in their patient safety capacity building activity. Case studies also offer a mechanism to share experiences and learning associated with using resources not listed in the Resource Map.

How to share your case study: If you have used any of the resources contained within the APPS Resource Map, or have identified a resource that may have utility in improving patient safety, email your feedback to [email protected] The APPS Core Team will review feedback and make periodic updates to the Resource Map. For general questions or comments related to the APPS Resource Map contact the APPS Core Team at [email protected]


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Rationale for including a resource: The resources listed within the APPS Resource Map version 2 are included after careful review of:     

WHO APPS-generated resources (WHO-APPS) WHO Patient Safety portfolio of resources (WHO PS); Other WHO departments working in fields related to patient safety (headquarters and regions) (WHO-General) A cross-section of international safety organizations, including United Nations partners and those involved in the prevention and control of health care-associated infections (Int Org) APPS partner-generated resources (APPS-Partner)

Inclusion criteria: Inclusion of a resource is based on the following criteria: o Perceived likelihood of utility of the resource in addressing the action areas contained within the APPS Situational Analysis. o Free availability and accessibility of full text versions of the resource at no cost. o Some evidence of practical application and evaluation in a health care context. There has been no scoring system developed in association with the inclusion criteria listed above, although consideration will be given to this for future versions. Inclusion of a resource does not imply endorsement by WHO of any specific organization associated with the resource.

Future considerations: The APPS Resource Map is currently available in hard copy (PDF and Word format). Over time the Map will be uploaded onto the APPS website and developed as an easily navigable web-based resource. Consideration is also being given to making the document available using digital technologies in particular the possibility of creating an APPS Resource Map Wiki (a collaborative web-based resource, which would allow multiple users across all of the international partnerships to create and modify some or all of its pages).


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Abbreviations Many of the resources listed within the APPS Resource Map were developed by national or international organizations. Where this is the case the user will see the relevant organizational abbreviations in brackets following the resource e.g. Act on Reporting (NPSA). Abbreviation AHRQ BEANISH CDC CEHA EMRO EVIPNET HICPAC HPA HUG IAPO IFC IFIC IHI ILO IPS ISQua JC JHPIEGO NCAS NELI NHS NHSI NICE NPSA

Organization/institution Agency for Healthcare Research and Quality Building Europe-Africa collaborative Network for Applying IST in Healthcare Sector Center for Disease Control WHO Regional Centre for Environmental Health Activities Eastern Mediterranean Regional Office of WHO Evidence Informed Policy Network (WHO) Healthcare Infection Control Practices Advisory Committee Health Protection Agency Hôpitaux Universitaires de Genève International Alliance of Patients Organizations International Finance Corporation International Federation of Infection Control Institute for Healthcare Improvement International Labour Organization Infection Prevention Society International Society for Quality and Safety in Health Care Joint Commission on Accreditation of Health Care Organizations International not-for-profit organization associated with Johns Hopkins National Clinical Assessment Service National Electronic Library of Infection National Health Service (UK) National Health Service Institute for Innovation and Improvement National Institute for Health and Clinical Excellence National Patient Safety Agency


Remit National/International International National/International International Regional International National National National/international International International International National/International International National International National/International International National National National National National National

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NPSF NRIC PAHO RCN SDC SEARO SHEA SIGN THET USAID WHO

National Patient Safety Foundation National Resource for Infection Control Pan American Health Organization Royal College of Nursing Swiss Agency for Development and Cooperation South East Asian Regional Office of WHO Society for Healthcare Epidemiology of America Safe Injection Global Network Tropical Health and Education Trust United States Agency for International Development World Health Organization


National National International National/International International Regional National International International International International

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Level 1

Action Area Matrix Introduction to the Action Area Matrix: Level 1 lists resources alphabetically under each action area using a matrix approach. Column headings relate to the questions asked within the Situational Analysis and provide the user with some insight into which areas of relevance the resource most addresses. The matrix is indicative only and will be refined based on user feedback.


Page reference for Level 3

Supervision

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Organizational culture

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Procurement

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Quality assurance

Act on Reporting (NPSA) Baldridge Criteria for Performance Excellence Framework BEANISH Initiative Blood Safety Range (WHO) Blue Trunk Library

Infrastructure

Action Area 1: Patient Safety and Health Services/Systems Development

Strategy and Planning


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Quality assurance

Building and nurturing an improvement culture: personal and organizational development (NHSI) Building on health systems frameworks for developing a common approach to health systems strengthening Clean Hands Save Lives, Alert 04 (NPSA) Development and Implementation of a Hospital based Patient Safety Program Global Trigger Tool (IHI) Guidance on developing quality and safety strategies within an health systems approach Handbook on monitoring and evaluation of human resources for health: with special applications for low- and middle-income countries (WHO) Health care Improvement Project (USAID) Health Statistics and Health Information Systems Toolkit for Monitoring Health Systems Strengthening (WHO) Hospital Survey on Patient Safety Culture (AHRQ) Leading Improvement in Patient Safety programme (NHSI) Lean range (NHSI) MaPSAF Range (NPSA) Modern Paradigm for Improving Health Care Quality (USAID) Patient Safety and Quality: An Evidence based Handbook for Nurses (AHRQ) Patient Safety and Quality Indicators (AHRQ) Patient Safety First Campaign Materials (NPSA) Patient Safety Friendly Hospital Initiative (PSFHI): An Entry Point to building a safer health System in Eastern Mediterranean region (EMR) Plan Do Study Act (NHSI) Quality Management System Manual for District Hospitals (IHI) Risk Assessment Range (NPSA) Safety Culture Assessment: A Tool for improving Patient Safety in Health



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Quality assurance

care Organizations Seven Steps range (NPSA) Team Climate Assessment Measures (NPSA) Transforming Care at the Bedside (IHI)



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Decision/policy making

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Patient safety guidelines

Patient safety regulation

Clinical Governance Support and Development Units Ethiopian National Patient Safety Policy EVIPNET Guidelines and Tools for Policy Briefs (WHO) The Health and Social Care Act 2008: Code of Practice for health and adult social care on the prevention and control of infections and related guidance (DH) Professionalism – dilemmas and lapses (NCAS) Speaking out for health, speaking out for nursing: policy statements on patient safety SUPPORT Tools for Evidence Informed Health Policy Making (STP) Toolkit for Accreditation Programmes (ISQua)

Hospital Leadership

Action Area 2: Links with National Policy on Patient Safety

Patient safety policy

Action Area 2: Links with National Policy on Patient Safety

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Ethiopia Public Health Training Initiative: Health Learning Materials Foresight Range (NPSA)

Incident Decision Tree (NPSA) Knowledge Management Toolkit (SDC) Learning from Error – video and booklet (WHO) National Electronic Library for infection (NELI) National resource for Infection Control (NRIC) Pareto (NHSI) Patient Safety and Quality Indicators (AHRQ)

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Training plans

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H1N1 Checklist How to Change Practice: Understand, Identify and Overcome Barriers to Change (NICE) How to put NICE Guidelines into Practice (NICE)

Patient care protocols

Clinical audit

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Act on Reporting; Five Actions to improve patient safety reporting (NPSA)

Adverse event reporting

Training/education

Action Area 3: Knowledge and Learning in Patient Safety

Links to training institutions


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Patient Safety Curriculum Materials (WHO) Patient Safety Research – A Guide for developing training programmes Patient Safety Research: Introductory course (on-line) (WHO) Patient Safety Solutions Peoples Open Access Education Initiative: Peoples-uni

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Training plans

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Safe Surgery Checklist (WHO) Unmet Needs: Teaching Physicians to Provide Safe Patient Care (NPSF)

Links to training institutions

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Practical Handbook for Clinical Audit by Clinical Governance Support Team, 2005 (NHS) Principles of Best Practise in Clinical Audit (NHS) RAFT Network

Mortality reviews

Checklists

Patient care protocols

Clinical audit

Adverse event reporting

Training/education


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cleanyourhands campaign (NPSA)

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Engaging Clinicians range (NPSA)

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Five Million Lives Campaign (IHI)

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Partnership for Clear Health Communication: Ask Me 3 Series (NPSF)

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Patient reporting

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Being Open Range (NPSA)

Awareness raising

Patients rights

Action Area 4: Patient Safety Awareness Raising

Public campaigns


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Patient engagement

What you can do to make Health Care Safer: A Consumer Factsheet (NPSF)

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Twenty Tips to help prevent Medical Errors: Patient Factsheet (AHRQ)

Public campaigns

Patients rights


cleanyourhands improvement strategy and toolkit (NPSA) Core Components for Infection Control Programmes (WHO) Getting Started: Reducing MRSA infection, How to Guide (IHI Five Million Lives Campaign) Guidance on Uniforms and work wear (RCN) Guideline for Disinfection and Sterilization in Health Care Facilities (CDC) Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (CDC) Guidelines for Prevention of Catheter Associated Urinary Tract Infections (CDC/HICPAC) Guidelines for Prevention of TB in resource limited settings

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Center for Disease Control and Prevention Making Healthcare Safer – Reducing Bloodstream Infections Clean Safe Care (Department of Health, UK)

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Structures/resources

A Compendium of Strategies to Prevent Healthcare-Associated Infection in Acute Care Hospitals (SHEA) nd A Practical Guide on the Prevention of Nosocomial Infections (2 edition) 2008 (WHO) Basic Concepts of Infection Control (IFIC)

Policies/Guidelines etc

Strategy/organization

Action Area 5: Health CareAssociated Infections

Training and education

Action Area 5: Health Care-Associated Infections

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Tools for Evaluation and Feedback: Data Summary Report Framework Tools for Evaluation and Feedback: Hand Hygiene Knowledge Questionnaire for Healthcare Workers Tools for Evaluation and Feedback: Hand Hygiene Technical Reference Manual Instructions for Data Entry and Analysis

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Observation Tools: Observation Form and Compliance Calculation Form Perception Survey for Healthcare Workers

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Perception Survey for Senior Managers

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Infection Prevention Guidelines for Facilities with Limited Resources (JHPIEGO) Multimodal Hand Hygiene Improvement Strategy and associated tools (WHO) (see tools listed below)  Tools for Evaluation and Feedback: Data Entry Analysis Tool

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Guide for National Public Health Laboratory Networking To Strengthen Integrated Disease Surveillance and Response (IDSR) (WHO/CDC) Guide to Implementation of the WHO Multimodal Hand Hygiene Improvement Strategy (WHO) Hand Hygiene in Outpatient and Home Based Care and Long-Term Care Facilities Infection Prevention and Control Minimum Standards (RCN and IPS)


Guidelines on Hand Hygiene in Health Care (WHO)



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Ward Infrastructure Survey

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Sustaining Improvement - Additional Activities for Consideration by Health-Care Facilities Tools for Institutional Safety Climate: Template Letter to Advocate Hand Hygiene to Managers Tools for Institutional Safety Climate: Template Letter to Communicate Hand Hygiene Initiatives to Managers Tools for Reminders in the Workplace: Hand Hygiene: When and How Leaflet Tools for Reminders in the Workplace: How to Handrub Poster

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Protocol for Evaluation and Comparison of Tolerability and Acceptability of Different Alcohol-based Handrubs: Method 2 Protocol for Evaluation of Tolerability and Acceptability of Alcoholbased Handrub in Use or Planned to be Introduced: Method 1 Soap/Handrub Consumption Survey


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Tools for System Change: Ward Infrastructure Survey

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Tools for System Change: Alcohol-based Handrub Planning and Costing Tool Tools for System Change: Guide to Local Production: WHOrecommended Handrub Formulations Tools for System Change: Protocol for Evaluation and Comparison of Tolerability and Acceptability of Different Alcohol-based Handrubs: Method 2 Tools for System Change: Protocol for Evaluation of Tolerability and Acceptability of Alcohol-based Handrub in Use or Planned to be Introduced: Method 1 Tools for System Change: Soap/Handrub Consumption Survey


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Natural Ventilation for Infection Control in Healthcare Settings (WHO)

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Sterilization Manual for Health Centers (PAHO) TB in the workplace (ICN) healthcare worker safety in the context of drug resistant TB in low and middle income countries Updated National Evidence-based Guidelines for Preventing HealthCare Associated Infection in NHS Hospitals in England 2007 (EPIC 2) US Department of Health and Human Services – Partnering to Heal: teaming up against Healthcare-Associated Infections WHO Policy on TB infection control in healthcare facilities, congregate settings and households WHO: Preventing Bloodstream Infection from Central Line Venous Catheters WHO Patient Safety Solutions

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NHS Evidence - Infections National resource for Infection Control, UK (NRIC)


Tools for Training/Education: Slides for Education Sessions for Trainers, Observers and Healthcare Workers  Tools for Training/Education: Slides for the Hand Hygiene Coordinator  Tools for Training/Education: Sustaining Improvement - Additional Activities for Consideration by Health-Care Facilities  Tools for Training/Education: Your 5 Moments for Hand Hygiene Poster National Electronic Library of Infection, UK (NELI)


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Guidelines on Health services and HIV/AIDS, 2005 (Joint ILO/WHO)

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Guidelines on post Exposure prophylaxis (PEP) to prevent HIV Infection, 2007 (Joint WHO/ILO) Health Protection Agency HIV and AIDS Information and Guidance in the Occupational Setting Protecting Healthcare workers: Preventing Needle stick injuries Toolkit (WHO) Revised Injection Safety Assessment Tool (2008) (WHO) Safe Injection Global Network (SIGN) Alliance range of resources (WHO) Sterilization Manual for Health Centers (PAHO)

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Immunization

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A Practical Guide on the Prevention of Nosocomial Infections (2 edition) 2008 (WHO) First Do No Harm: Introducing Autoclavable Syringes and ensuring injection safety in immunization systems of developing countries (WHO) Guidance Note on healthcare worker safety from HIV and other blood borne infections, Human Development Network (World bank) Guidelines for Prevention of TB in resource limited settings (WHO)

Monitoring of accidents

Policies/guidelines

Action Area 6: Healthcare Worker Protection

Availability of Personal Protective Equipment (PPE)

Action Area 6: Healthcare Worker Protection



 

84 84



84 84

  

 





 











  

 

 



85 85



85

 

85 86 86

  








 

86 86



86



87

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Data collection/budgeting

Waste and home care

Single-use items

Decontamination

Pest control

Storage

Handling  


 


Assessment of Small Scale Incinerators for Healthcare Waste (WHO) Basic steps in the preparation of healthcare waste management plan for Health Care Establishments (WHO EMRO and CEHA) Costing Analysis Tool for Healthcare waste Management (WHO) Guidance for the Development and implementation of a National Action Plan, 2004 (WHO) Managing Healthcare Waste Disposal Management of Solid Healthcare Waste Management at Primary Health Care Centres – A Decision Making Guide (WHO) Management of waste from injection activities at district level- Guidelines for District health Managers (WHO) National Healthcare Waste Management Plan, 2009 (Angola) PATH Resources on Health care waste management Preparation of National Healthcare Waste Management Plans in Sub-Saharan Countries (WHO) Rapid Assessment Tool for Country level (WHO) Safe Healthcare Waste Management: for a national strategy for healthcare waste management, Aide Memoire (WHO) Starting Healthcare Waste Management in Medical institutions- A Practical Approach (WHO EURO) Sterilization Manual for Health Centers (PAHO)

Supplies

Action Area 7: Healthcare Waste Management

Policy/guidelines/protocols


Action Area 8: Safe Surgical Care



  

   

 






88 88 88

 



        

        







88 89 89 89 89 90 90 90 90 90 90 90 90 90 91 91 91

Page 25 of 117






Complications reporting

Mortality reporting

Equipment

 

Checklists

Guidelines: Surgical Site Infection (NICE) Guidelines for Safe Surgery (WHO) Integrated Management for Emergency and Essential Surgical Care (IMEESC) tool kit (WHO) Surgery and Healing in the Developing World (2005) Surgery in Africa – Monthly Review Surgical Care at District Hospital (WHO) Surgical Checklist Range (NPSA) Surgical Safety Checklist (WHO) Surgical Safety Checklist –Implementation tools (WHO)  Surgical Safety Checklist - Checklist Implementation Manual (WHO)  Surgical Safety Checklist - Frequently Asked Questions (WHO)  Surgical Safety Checklist - How NOT to Use the Checklist (WHO)  Surgical Safety Checklist - How to Use the Checklist, Complex Case Video (WHO)  Surgical Safety Checklist - How to Use the Checklist Video (WHO)  Surgical Safety Checklist - Safe Surgery Brochure (WHO)  Surgical Safety Checklist - Safe Surgery Checklist Modification Guidelines (WHO)  Surgical Safety Checklist - Speakers' Kit (WHO)  Surgical Safety Checklist - Starter Kit (WHO) Universal Protocol for Preventing Wrong site, Wrong Procedure, Wrong person Surgery: Guidance for Health Care Professionals (JC) WHO Patient Safety Solutions

Structures

Human resources


114

Action Area 9: Medication Safety

      

 












  



 

  

92 92 92 92



93 93 93 94 94



95



 

Page 26 of 117


 


Documentation

Reporting

Formularies

Procurement

Human resources  


  


Assuring Medication Accuracy at Transitions in Care (WHO) Basel Statements on the Future of Hospital Pharmacy Control of Concentrated Electrolyte Solutions – Patient Safety Solutions (WHO) Creation of a better medication safety culture in Europe: Building up safe medication systems Look Alike, Sound Alike Medication Names – Patient Safety Solutions (WHO) Medicines Reconciliation, (NPSA/NICE) Potassium Chloride, Alert 01, (NPSA) Resources from Global Conference on Future Hospital Pharmacy, 2008 Safety of medicines , A Guide to detecting and reporting Adverse Drug Reactions Why Health professionals need to take action (WHO) WHO Patient Safety Solutions

Organization

Policy/guidelines


114

Action Area 10: Patient Safety Partnerships

Seven Steps range (NPSA) Speak Up Initiatives for Patients (JC) Stakeholder Analysis: How to do (or not to do) Toolkit on Monitoring and Evaluation for Health Links (THET) Twenty Tips to help prevent Medical Errors: Patient Factsheet (AHRQ) What is Patient Centered Health Care: A Review of Definitions and Principles (IAPO) What you can do to make Health Care Safer: A Consumer Factsheet (NPSF)

     

 

    

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

 





96







 

   


  

  





 

 

 

96 96 97 97 97 98 98 98 99 99 99 100 100

Page 27 of 117






Policy

Culture

Feedback mechanisms

Structures



Outreach

An assessment of community engagement and community development approaches including the collaborative methodology and community champions (NICE) Being Open Range, UK (NPSA) nd International Health Links Manual 2 Edition (THET) Measuring the Community Connections : A strategy checklist for Leaders, 2006 Partnership for Clear Health Communication: Ask Me 3 Series (NPSF) Patient Centred Care Improvement Guide (IHI) Patient Safety Champions (WHO)

Organization

Engagement


Action Area 11: Patient Safety Funding

 


  







101 101



101

 







102 102 102

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


Public Private Partnership

Supplies

Salaries

Health care financing

Budget allocation

 



Forward planning

CostIT software (WHO) Health Statistics and Health Information Systems Toolkit for Monitoring Health Systems Strengthening (WHO) The Business of Health in Africa – Partnering with the Private Sector to Improve Peoples Lives (IFC/World Bank) The Economic Case: Implementing near-patient handrub in your trust (NPSA) The Socio-economic Burden of Hospital Acquired Infection (HPA) Tools for System Change: Alcohol-based Handrub Planning and Costing Tool (WHO)

Funding sources

Organization and strategy







Surveillance systems

Evaluation

Knowledge translation

Solutions for Patient Safety  



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


 


Being Open Range (NPSA) Global Priorities for Research in Patient Safety (WHO) Guidance for Selecting and Using Core Indicators for Cross-Country Comparisons of Health Facility Readiness to Provide Services (USAID) Guide for National Public Health Laboratory Networking To Strengthen Integrated Disease Surveillance and Response (IDSR) (WHO/CDC) Improving Data Quality – A Guide for Developing Countries (WHO) Patient Safety Case Studies in Patient Safety Research Series (WHO) Patient Safety Research: Introductory course (on-line) (WHO) RAFT Network (HUG) Research Information Booklet (WHO) 7 Steps range (NPSA)

Causes of Patient Safety problems

Strategy

Academia

Action Area 12: Patient Safety Surveillance and Research

Measurement of Patient Safety


103 103 103

115

104 105 105 105 106 107 107

Page 29 of 117

115

Level 2

Key Information The purpose of Level 2 is to present the user with key information about the resource, highlighting the potential benefits and challenges associated with its use. Level 2 is an important level, it is here that the user will most likely make a decision as to whether the resource should be accessed. The fourth column provides information on where to source the resource and lists web links where available. The final column indicates whether case study information is available.

Action Area 1: Patient Safety and Health Services and Systems Development Action Area 1: Patient Safety and Health Services and Systems Development

Purpose

Benefits and challenges

Where to find

Case study page no.

Act on Reporting (NPSA)

Sets out 5 key actions that all NHS organizations can make to improve reporting and learning and move towards high reliability. The five key actions are; i) give feedback to staff; ii) focus on learning; iii) engage frontline staff; iv) make it easy to report; v) make reporting matter.

The Briefing is based on the outcome of a seminar for high-reporting NHS organizations and therefore emerged directly from real-world experiences.

 NPSA general website: www.npsa.nhs.uk  The Act on Reporting Briefing document is available at www.nrls.npsa.nhs.uk/resources/pati ent-safety-topics/risk-assessmentmanagement

108

Baldridge Criteria for Performance Excellence Framework

The Baldrige National Quality Program was established in the USA in 1987. At its centre lie the Baldrige Criteria for Performance Excellence. These are a series of questions examining the performance of whole organisations. They are widely used as an assessment and improvement tool for

Organisations can use the Baldrige criteria to:  Enhance their awareness of areas of strength, and seek to build on these  Enhance their awareness of opportunities for improvement,

To access the 2009-2010 Health Care Criteria for Performance Excellence and a self-analysis worksheet: http://www.baldrige.nist.gov/HealthCar e_Criteria.htm


Page 30 of 117

Action Area 1: Patient Safety and Health Services and Systems Development

BEANISH Initiative

Blood Safety Range of resources (WHO)

Purpose

organizations. The criteria have been specifically adapted for use by healthcare organisations. The majority of American states and many countries have improvement programmes modelled on the Baldrige approach. The BEANISH initiative, proposed by EU-African partners and IFIP (International Federation for Information Processing) builds upon an existing global research and development network called HISP (Health Information Systems Program). This initiative seeks to involve various institutional actors (government, universities, private sector and NGOs) to strengthen and extend an existing Europe-Africa collaborative network to support the application and sharing of information society technologies application development so as to support cooperation, learning and innovation in mutually beneficial ways. A comprehensive collection of Resources from WHO Blood Transfusion Safety and Blood Products and Biologicals. Resources consist of WHO technical Guidance and Quality Assurance tools for Regulatory Authorities such as Aide memoirs for Safe Clinical use of Blood, Strategies and Recommendations for Universal Access to safe Blood Transfusion and Recommendations for Screening Donated Blood for transfusion transmissible infections.


Where to find

Case study page no.

and seek to achieve these The criteria provide a systematic means of examining an organisation’s performance. Through a collaborative network BEANISH builds tools and capacity in the use of routine health information for improved health care delivery. Free and Open Source software for collection, analysis, interpretation and reporting of health data is developed in a South-South-North collaborative network. In-service training is offered to health workers, focusing on basic computer skills as well as data management, analysis and interpretation in order to inform decision-making and facilitate evidence-based health care management.

http://www.witfor.org.bw/themes/docum ents/beanish_profile.pdf

Blood Safety forms an integral part of any patient safety program. These resources will assist health care institutions and authorities in framing national/regional strategies to prevent adverse events due to unsafe blood.

Complete range of resources can be accessed from the following links: Blood Transfusion Safetyhttp://www.who.int/bloodsafety/en/

Blood products and Biologicalshttp://www.who.int/bloodproducts/en/

All these resources address some of the major issues related to blood and blood products safety such as infections during transfusion, limited


Page 31 of 117


Purpose


Where to find

Case study page no.

This has been developed by the Library of the World Health Organization for installation in district health centres in Africa as a means of compensating for the lack of up-to-date medical and health information. Available in English, French, Portuguese and Arabic

http://www.who.int/ghl/mobile_libraries/ bluetrunk/en/index.html

access to safe blood and lack of National policy/guidelines for blood safety specifically in developing countries. Blue Trunk Library, WHO

This is a collection of books on pubic health developed by the WHO library and caters to the needs of African countries with lack of updated information on clinical and public health.

Each blue truck library costs USD 2000 and has been supported by Ministries of Health and International Donors in respective countries. Building and nurturing an improvement culture: personal and organizational development (NHSI)

Published in 2005, this guide suggests ideas on how to create an improvement culture for a team. It argues that culture influences how people think, what they see as important, how they behave, which may determine the success of any improvement work. By sharing values and ideas about working practices, and using techniques that create shared beliefs, the prospect of improvement has a greater chance of being realized and sustained.

Part of the Improvement Leaders guide series of the NHS Institute, this 60 page guide to improving culture offers an interesting insight into the multiple factors which impact on culture.

Available to NHS employees by registering with the UK NHS Institute for innovation and Improvement http://www.institute.nhs.uk

Building on health Systems Frameworks for Developing a Common Approach to Health Systems Strengthening

Strong and effective health systems are increasingly considered a prerequisite to reducing the disease burden and to achieving the health MDGs, rather than the outcome of increased investments in disease control. As a consequence, health systems strengthening (HSS) has risen to the top of the health development

The growing demand for HSS investments in countries, and growing commitments of global health initiatives and collaborating agencies to support HSS, demonstrate recognition of the need to accompany the scale-up of stand-alone programs with broader health system strengthening. The expression of growing needs for

http://siteresources.worldbank.org/INT HSD/Resources/3762781114111154043/10118341246449110524/HealthSystemFramew orksFINAL.pdf


Page 32 of 117


Purpose


agenda.

HSS investments from countries, the commitment from key donor agencies to meet those needs, and the WHOfacilitated process to strengthen synergies among technical partners – have produced increased momentum for enhancing the overall effectiveness and efficiency of HSS interventions globally. The Alert provides an illustration of a centrally issued directive instructing all NHS hospitals to ensure alcohol-based handrubs are available at the point of care.

Clean Hands Save Lives: Alert 04 (NPSA)

This Patient Safety Alert provides guidance on best practice in hand hygiene at the point of care, to contribute to reducing healthcare associated infection (HCAI).

Development and Implementation of a Hospital based Patient Safety Program

An article published in the Journal of Paediatric Radiology (2006) which gives an overview of the implementation of a Hospital Patient Safety Program in the Duke University Health System. The program specifically includes development of safety teams, provision of safety support tools, and how to identify and respond to patient/staff needs and priorities. The article contains a template for evaluation of safety concerns (Table 1). The second edition (2009) of this Tool for Measuring Adverse Events is described by IHI as an easy-to-use method for accurately identifying adverse events (harm) and measuring the rate of adverse events over time which can help to illustrate whether improvements are being made. This was developed to provide independent and research based

Global Trigger Tool for Measuring Adverse Events (IHI)

Guidance on developing quality and safety strategy

Where to find

Case study page no.

 NPSA general website: www.npsa.nhs.uk  A PDF version of the Alert can be downloaded at: http://www.nrls.npsa.nhs.uk/resource s/?entryid45=59848&q=0%c2%accle an+hands%c2%ac

Benefit: Steps in implementation can be adopted by hospitals from various health systems incorporating the lessons learnt from the Duke University Health System program.

http://www.springerlink.com/content/v7 6638h36mn48116/fulltext.pdf

The 46 page tool outlines the method for measurement, which incorporates a retrospective review of a random sample of case notes. The tool is a feature of IHIs Five Million Lives Campaign and has been extensively used both within and outside the US.

The main IHI website: Accessing the Global Trigger Tool requires you to first log-in to the IHI site, which is possible via: www.ihi.org .

Factors such as: increased expectations on healthcare services

http://www.euro.who.int/__data/ass ets/pdf_file/0011/96473/E91317.pd


Page 33 of 117


Purpose


Where to find

within a health system approach

guidance for developing a national quality and safety strategy which is suited to a country's situation. It is targeting senior health policy makers and advisers; and quality leaders involved in the process of strategy development and decision making

and provision; increased changing health needs; change in cost of healthcare services; skills shortages and increasing labour and patient mobility etc. all contribute to the need for quality and safety improvement in country's healthcare can lower costs and advance human rights and can therefore contribute to the best attainable level of health (including its social dimension) and wealth of a country. A well developed quality policy and strategy will reduce the obstacles to improvement and will mobilize stakeholders to act towards attaining higher quality services.

f

Handbook on monitoring and evaluation of human resources for health: with special applications for lowand middle-income countries (WHO)

This 196 page handbook was published in 2009 by WHO in association with the World Bank and USAID. It addresses general workforce issues related to entry and exit of personnel as well as measurement strategies and the use of facility based assessments for monitoring the health workforce. The handbook concludes with a focus on strategies to get evidence in policy and practice. The USAID Health Care Improvement Project (HCI) provides support to countries in improving quality and impact of health services building on the successes of the Quality Assurance Project (1990-2007). The website contains useful resources including a global improvement database and a range of improvement tools for use in key focus areas including patient safety. This toolkit has been developed through collaboration between WHO, the World Bank, country health

Health Care Improvement Project (USAID)

Health Statistics and Health Information Systems Toolkit for Monitoring Health

Case study page no.

English version: http://whqlibdoc.who.int/publications/20 09/9789241547703_eng.pdf French version: http://whqlibdoc.who.int/publications/20 09/9789242547702_fre.pdf

Benefits: Wide collection of evidence based and context specific resources considering USAID's ongoing work and familiarity with the African health care settings.

http://hciproject.org/

Regularly updated database provides an opportunity to learn from real experiences.

The toolkit is currently in draft form and comments are invited from users. The Toolkit is comprised of a series of


General information on the toolkit: http://www.who.int/healthinfo/statistics/t oolkit_hss/en/

Page 34 of 117


Purpose


Where to find

Systems Strengthening (WHO)

information and systems experts and many other organizations working in this field. It describes a set of indicators and related measurement strategies covering the core health system building blocks.

separate toolkits addressing:  Service delivery  Information systems  Financing  Human resources  Medical products  Governance



Hospital Survey on patient Safety Culture (AHRQ)

ARHQ sponsored the development of patient safety assessment tools for hospitals, nursing homes and outpatient departments. The tools are intended to enable hospitals to assess their patient safety cultures; track changes in patient safety over time and evaluate the impact of patient safety interventions. The Leading Improvement in Patient Safety (LIPS) programme is about building the capacity and capability within hospital teams to improve patient safety.

The AHRQ hospital tool is currently being used by the WHO High Fives Programme. It is described as userfriendly.

Leading Improvement in Patient Safety programme (NHSI)

The programme aims to help NHS trusts develop organisational plans for patient safety improvements and to build teams responsible for driving improvement across their organisation. A modular programme delivered over a 12 month period. Modules are aimed at different people within the organization,


Case study page no.

Service delivery: http://www.who.int/healthinfo/statis tics/toolkit_hss/EN_PDF_Toolkit_H SS_ServiceDelivery.pdf  Information systems: http://www.who.int/healthinfo/statis tics/toolkit_hss/EN_PDF_Toolkit_H SS_InformationSystems.pdf  Financing: http://www.who.int/healthinfo/statis tics/toolkit_hss/EN_PDF_Toolkit_H SS_Financing.pdf  Human resources: http://www.who.int/healthinfo/statis tics/toolkit_hss/EN_PDF_Toolkit_H SS_HumanResources_oct08.pdf  Medical products: http://www.who.int/healthinfo/statis tics/toolkit_hss/EN_PDF_Toolkit_H SS_MedicalProducts.pdf  Governance: http://www.who.int/healthinfo/statis tics/toolkit_hss/EN_PDF_Toolkit_H SS_Governance.pdf The general AHRQ website: http://www.ahrq.gov/ PDF and word versions of the hospital survey tool and user guide, and excel spreadsheet versions of the data entry and analysis tool can be downloaded at: http://www.ahrq.gov/qual/patientsafetyc ulture/hospsurvindex.htm More information is available from the NHS Institute for Innovation and Improvement website: http://www.institute.nhs.uk/safer_care/s afer_care/safer_care__home_page_2.html

108-109

Page 35 of 117


Purpose

Lean Range (NHSI)

Lean is an improvement approach to improve flow and eliminate waste that was developed by Toyota. Lean is basically about getting the right things to the right place, at the right time, in the right quantities, while minimising waste and being flexible and open to change.

Manchester Patient Safety Framework (range) (NPSA)

The NPSA and a team from the School of Psychological Sciences at the University of Manchester devised the MaPSaF range to help NHS organizations assess their progress in developing a safety culture. MaPSaF has been designed as a self-reflective framework and not as a tool for performance management.

Modern Paradigm for Improving Health Care Quality (USAID)

Prepared under the Quality Assurance Project (QAP) for use in developing countries, this document gives an overview of various approaches for improving quality in health care. It presents a framework for quality


from chief executives and their executive teams to medical, nursing, finance and operational directors and senior clinicians through to patient safety managers and other operational staff. The programme is backed-up with the following resources: Introductory film, programme structure and modules, supporting materials and delegate stories, the opportunity to follow NHS organizations on their journey via the website. The NHSI site presents a useful introduction to Lean as an approach to designing or redesigning services to ensure that health care work adds value to patient care. Where there is work or services that do not add value, resources can be diverted to those that do add value. Lean is about delivering a higher quality service to patients by reducing waste in the system. MAPSAF can help to stimulate discussion about the strengths, weaknesses and differences of the patient safety culture in a team, between staff groups or in an organisation. Time consuming. May be wrongly perceived as a performance management tool for comparing or benchmarking organizations. Describes a set of simple, flexible and evidence based approaches to quality improvement in health care which can be selected according to the applicability in the local context.


Where to find

Case study page no.

General information on Lean can be found at: http://www.institute.nhs.uk/quality_and _service_improvement_tools/quality_a nd_service_improvement_tools/lean.ht ml

NPSA general website: www.npsa.nhs.uk PDF copies of the MaPSaF for acute hospitals and a safety culture PowerPoint presentation, are available for download at http://www.nrls.npsa.nhs.uk/resources/ ?entryid45=59796

http://www.hciproject.org/node/899

Page 36 of 117


Patient Safety and Quality: An Evidence based Handbook for Nurses (AHRQ)

Patient Safety and Quality Indicators (AHRQ)

Patient Safety First Campaign

Purpose

improvement based on four principles which include focus on client, understanding work as processes and systems, teamwork and testing changes to processes and systems using data. The document provides a number of Quality Improvement tools such as data collection, analysis and process description tools with examples This resource is intended to assist nurses in their vital role in improving the safety and quality of patient care. It describes proven techniques and interventions they can use to enhance patient outcomes.

The AHRQ Quality Indicators (QIs) measure health care quality by using readily available hospital inpatient administrative data. The Patient Safety Indicators (PSIs) are a tool to help health system leaders identify potential adverse events occurring during hospitalization. The PSIs are a set of indicators providing information on potential in hospital complications and adverse events following surgeries, procedures, and childbirth.

Patient Safety First is a campaign sponsored by the National Patient


Where to find

Case study page no.

This comprehensive, 1,400-page, handbook for nurses on patient safety and quality has been compiled by experts in the field following a review of the literature. It is grouped into sections: Patient Safety and Quality / Evidence-based Practice / Patientcentered Care / Working Conditions— Work Environment / Critical Opportunities for Patient Safety and Quality / Tools. The entire volume can be downloaded free of charge as a PDF (10 MB) or individual chapters can be downloaded. The PSIs were developed after a comprehensive literature review, analysis of ICD-9-CM codes, review by a clinician panel, implementation of risk adjustment, and empirical analyses.

Access the AHRQ complete range of resources at: http://www.ahrq.gov/qual/pstools.htm Access this resource at: http://www.ahrq.gov/qual/nurseshdbk/n urseshdbk.pdf

Access the AHRQ complete range of resources at: http://www.ahrq.gov/qual/pstools.htm Access this resource at: http://www.qualityindicators.ahrq.gov/m odules/psi_overview.aspx

The PSIs are a software tool distributed free by AHRQ. The software can be used to help hospitals identify potential adverse events that might need further study. The PSI software programs can be applied to any hospital inpatient administrative data. The campaign is designed for the UK health care system. Useful campaign


 General campaign website: http://www.patientsafetyfirst.nhs.uk/c

Page 37 of 117


Patient Safety Friendly Hospital Initiative (PSFHI): An Entry Point to building a safer health System in Eastern Mediterranean region (EMR)

Purpose


Where to find

Safety Agency, the NHS Institute for Innovation and Improvement and The Health Foundation. The campaign, which is underpinned by improvement methodology, has been developed by a team of clinicians and managers experienced in patient safety. It consists of a range of materials to assist with implementation and evaluation. The campaign interventions are:  Leadership for safety;  Care of the deteriorating patient;  Critical care: central line and ventilator bundles;  Perioperative care: surgical site infection bundle and WHO Safe Surgery Checklist  Reduction of harm from high risk medication

materials include a:  Quick Guide to Implementing Improvement (13 pages)  How to Guide for Implementing Human Factors in Health Care  Guide to Communication  Templates for letters

This is a paper published in International Hospital Federation Reference Book (2007-08), which describes PSFHI, generated by collaborative work of WHO EMRO and countries in the Eastern Mediterranean Region. PSFHI is a framework that provides an umbrella for all patient safety elements and activities at the hospital setting. The framework has been adopted by some countries to enhance patient safety as a national programme.

This document can be utilized by health care professionals and hospital managers to improve hospital patient safety by adopting the framework for different health systems considering the local context. It can particularly be effective in developing country context as it was developed and tested in the Eastern Mediterranean Region.

ontent.aspx?path=/  A PDF of the Quick Guide to Implementing Improvement is available at: http://www.patientsafetyfirst.nhs.uk/a shx/Asset.ashx?path=/How-toguides-2008-0919/Quick%20Guide%201.1_17sept0 8.pdf  A PDF of the How to Guide for Implementing Human Factors in Health Care: http://www.patientsafetyfirst.nhs.uk/a shx/Asset.ashx?path=/Interventionsupport/Human%20Factors%20Howto%20Guide%20v1.2.pdf  A PDF of the Guide to Communication: http://www.patientsafetyfirst.nhs.uk/a shx/Asset.ashx?path=/supportmaterials/A%20Guide%20to%20Co mmunicating%20the%20Patient%20 Safety%20First%20campaign%20for %20England%20v2.pdf  A PDF letter template is available at: http://www.patientsafetyfirst.nhs.uk/a shx/Asset.ashx?path=/GettingStarted/Sign%20Up%20Form.pdf Access details of this initiative: http://www.isqua.org/docs/fellow-pointdocument/case-study-patient-safetyfriendly-hospital-initiative.pdf?sfvrsn=0


Case study page no.

Page 38 of 117


Purpose


Where to find

Plan Do Study Act (NHSI)

Plan Do Study Act (PDSA) cycles help to ensure that new ideas relating to improvements are sufficiently tested prior to wide scale implementation. PDSA is a quality improvement tool.

PDSA cycles are presented as part of an overall improvement guide, which provides a framework for developing, testing and implementing changes leading to improvement. The model is based in scientific methods which have been increasingly used across the world. The NHSI website provides a useful and brief overview of the approach.

General information on PDSA cycles can be found at: http://www.institute.nhs.uk/quality_and _service_improvement_tools/quality_a nd_service_improvement_tools/plan_d o_study_act.html

Quality Management System Manual for District Hospitals (IHI)

This manual gives guidance for district hospitals for introducing and developing a quality management system (QMS). In part 1, the manual explains what we mean by quality, why we need to improve quality and how we can do so. Part 2: describes a quality management system, why a hospital needs one and how to introduce one. Part 3: gives details of how a quality management system works in practice and an outline for a training course for quality supervisors

This QMS has been developed for district hospitals where written standards and supervision are not widely or consistently practiced.

Access this resource by registering on the IHI website at: http://www.ihi.org/IHI/Topics/Improvem ent/ImprovementMethods/Tools/Quality ManagementSystemManualforDistrictH ospitals.htm

Risk Assessment Range (2006) (NPSA)

The National Reporting and Learning Service (NRLS) of the NPSA have developed a series of guides to support NHS staff in the process of risk assessment and management. The range comprises of 3 guides:  An overview - describing the NRLS’s risk assessment work programme. It suggests tools and techniques that local NHS organisations can use in their risk management approach.  A guide for general practice, clinicians and local (integrated) commissioning groups  A guide for commissioners of out-of-

A concise (24 page) outline of the risk assessment process which introduces models of risk assessment such as Failure Modes and Effects Analysis. Useful starting point for those with little expertise of risk assessment in health care, targeted to the UK health system.

NPSA general website: www.npsa.nhs.uk PDFs of the 3 guides relating to the Risk Assessment Programme can be found at: http://www.nrls.npsa.nhs.uk/resources/ ?entryid45=59813&q=0%c2%acrisk+as sessment%c2%ac


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Action Area 1: Patient Safety and Health Services and Systems Development Safety Culture Assessment : A Tool for improving Patient Safety in Health care Organizations

Seven Steps range (NPSA)

Purpose

hours (OOH) services. A paper which gives an overview of different tools that can be utilized by Health Care Organizations and hospitals to assess the existing safety culture in order to improve patient safety with a special focus on diagnosing culture, bench marking, stakeholder engagement and safety assessment data collection. A guide for staff who provide care in the NHS, England, and for those involved in risk management and clinical governance. The 7 Steps centre on culture, leadership, integration of risk management, promotion of reporting, patient involvement, learning and sharing and implementation.


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Access this resource by registering on: http://qshc.bmj.com/content/12/suppl_2 /ii17.full.pdf

Useful information which can be modified for planning patient safety improvements in each of the 7 areas. The summary document can be used as a quick reference manual.

NPSA general website: www.npsa.nhs.uk The 7 Steps range includes a generic resource, a summary document, a resource tailored to mental health and a resource tailored to primary care, available at http://www.nrls.npsa.nhs.uk/resources/ ?entryid45=59787&q=0%c2%acseven +steps%c2%ac

Team Climate Assessment Measures Programme (NPSA)

The Team Climate Assessment Measure (TCAM) programme measures teamwork, particularly behaviours essential to the maintenance of patient safety and effective patient safety incident management in clinical settings. It also gives staff the opportunity to improve their team working.

In its present format the TCAM programme is facilitated by a coordinator who administers a questionnaire, produces a report, and arranges and facilitates a series of development sessions. Transferability of the approach to the APPS context would require some further discussion.

NPSA general website: www.npsa.nhs.uk Some additional information on the TCAM Programme is available at: http://www.nrls.npsa.nhs.uk/resources/ ?entryid45=59884&q=0%c2%acteam+ climate+assessment%c2%ac

Transforming Care at the Bedside (IHI)

Through an initiative called Transforming Care at the Bedside (TCAB), IHI and RWJF created a framework for change on medical/surgical units built around improvements in four main categories: • Safety and Reliability • Care Team Vitality • Patient-Centeredness

This paper describes work in progress at 13 pilot hospitals, where staff are testing, refining and implementing change ideas within each category. Early results are promising, and the paper offers concrete suggestions for readers who wish to test and implement similar ideas in their own hospitals.

Access this resource: http://www.ihi.org/offerings/Initiatives/P astStrategicInitiatives/TCAB/Pages/def ault.aspx


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Purpose


• Increased Value The paper emphasises that Transforming Care at the Bedside requires a commitment to changing the status quo.

In this paper, IHI and RWJF offer hospitals a number of ideas to test, adapt, and implement as appropriate.


Where to find

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Action Area 2: National Patient Safety Policy Action Area 2: National Patient Safety Policy

Purpose


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Clinical governance support and development units

The standards for health services in Wales set out the Welsh Government's common framework of standards to support the NHS and partner organizations in providing effective, timely and quality services across all healthcare settings.

Standards provide a consistent framework that enables health services to look across the range of their services in an integrated way to ensure that all that they do is of the highest quality and that they are "doing the right thing, at the right time, for the right patient in the right place and with the right staff".

http://www.wales.nhs.uk/sites3/home.cf m?orgid=419

Ethiopian National Patient Safety Policy

The policy addresses: Leadership and Management; Patient Flow; Medical Records Management; Pharmacy Services; Laboratories; Nursing Care Standards; Infection Prevention; Facilities; Medical Equipment Management; Financial and Asset Management; Human Resource Management; Quality Management and Monitoring and Reporting.

This is an example of policy development emerging from an African context.

http://ezcollab.who.int/apps

EVIPNET Guidelines and Tools for Policy Briefs

A collection of tools from WHO EVIPNET (Evidence Informed Policy Network) including 'Terms of Reference' and 'Policy Brief Checklist' that aids in the conversion of research evidence into policy briefs on public heath issues.

Benefit: A comprehensive yet concise way of capturing and utilizing research evidence for framing health policies which is easy to follow and replicate in different health systems.

http://www.evipnet.org/php/level.php?la ng=en&component=103&item=8

http://www.nhswalesgovernance.com/di splay/Home.aspx?a=130&s=2&m=0&d= 0&p=0

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Sets of questions provided in the Terms of Reference, guide the user in considering local applicability, equity and scaling up The Health and Social Care Act 2008: Code of Practice for health and adult social care on the prevention and control of infections and related guidance (DH)

The Code sets out what providers of health care should do to comply with the inspectorate (Care Quality Commission) registration requirements for cleanliness and infection control. It sets out 10 criteria against which health care providers will be judged

Published in 2009 for the English NHS frameworks and regulations, the 10 criteria described within the code offer a potentially useful starting point for any organization wanting to develop criteria against which to monitor infection prevention and cleanliness activities. The table presented on page 34 offers a potentially useful guide as to which


Access the Code: http://www.dh.gov.uk/prod_consum_dh/ groups/dh_digitalassets/documents/digit alasset/dh_110435.pdf

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Action Area 2: National Patient Safety Policy Professionalism – dilemmas and lapses (NCAS)

Speaking out for health, speaking out for Nursing: Policy Statement on Patient Safety

SUPPORT Tools for Evidence Informed Health Policy Making (STP)

Purpose

This guide identifies principles to guide individual professionals and those responsible for managing professionalism in practice when dealing with concerns about professional practice. It is intended to provoke discussion within healthcare organisations about how professionalism is promoted in practice, and in particular it is targeted at those considering how lapses are identified and managed. Patient safety has emerged as a priority national and provincial issue in health care. The evidence suggests many errors can be prevented. It is therefore incumbent on all health care providers, organizations, and governments to create cultures of safety that support safe practice for both patients and staff.

A series of articles with tools published by the Journal of Health Research Policy and Systems (HARPS), as a part of the SUPPORT (SUPporting POlicy relevant Reviews and Trials) Project, an international collaboration funded by the European Commission. These tools can be of potential use to all those who are involved in using research evidence to improve the effectiveness of policy decisions. A set of 17 support tools and set of questions that assist in evidence informed policy making and covers four major aspects including supporting evidence informed policy making, identifying needs for evidence, finding


Where to find

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criteria applies to a range of health care activity. Developed specifically for the UK NHS.

http://www.ncas.npsa.nhs.uk/resources/

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All individuals have a right to safe effective care in all sectors in all practice settings. The Registered Nurses Association of Ontario asserts that collective action at all levels to address system issues and supporting registered nurses in providing optimal patient will create a safer health care system, evident by quality outcomes to patients, organizations/communities, the system and the nursing profession These tools can be beneficial to those working with policy makers, civil servants, legislative appointees and government health officials in order to facilitate the use of evidence in decision making. Tools will be available in Chinese, French, Spanish and Portuguese shortly.


http://www.rnao.org/Page.asp?PageID= 122&ContentID=1080&SiteNodeID=471

The entire range can be accessed at: http://www.health-policysystems.com/supplements/7/S1

The Preparing and Using Policy Briefs to Support Evidence Informed Policy Making tool can be accessed at: http://www.health-policysystems.com/content/pdf/1478-4505-7S1-S13.pdf

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Action Area 2: National Patient Safety Policy

Purpose


Where to find

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and assessing evidence and going from evidence to policy decisions. Additional information resources listed in each article can be utilized for further exploration on specific topics.

Toolkit for Accreditation Programmes (ISQua)

Of special relevance is one of the SUPPORT Tools called Preparing and Using Policy Briefs to Support Evidence Informed Policy Making which contains a set of questions that can be utilized as a guide for packaging research evidence in order to prepare a policy brief for addressing specific issues e.g. patient safety. The International Society for Quality in Health Care (ISQua) have developed a Toolkit for Accrditation Programs, to assist accreditation providers, funding agencies, intergovernmental organizations, and individual countries considering the development of a national health care accreditation program. The toolkit discusses priority issues for consideration when beginning an accreditation program, including policy issues, functions of a national accreditation agency, management of the accreditation process, and resource requirements.


Access the toolkit: http://siteresources.worldbank.org/HEAL THNUTRITIONANDPOPULATION/Reso urces/ToolkitForAccreditationProgramsI SQua.pdf

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Action Area 3: Knowledge and Learning in Patient Safety Action Area 3: Knowledge and Learning in Patient Safety

Purpose


Where to find

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Act on Reporting; Five Actions to improve patient safety reporting (NPSA)

Sets out 5 key actions that all NHS organizations can make to improve reporting and learning and move towards high reliability. The five key actions are; i) give feedback to staff; ii) focus on learning; iii) engage frontline staff; iv) make it easy to report; v) make reporting matter.

The Briefing is based on the outcome of a seminar for high-reporting NHS organizations and therefore emerged directly from real-world experiences.

 NPSA general website: www.npsa.nhs.uk  The Act on Reporting Briefing document is available at www.nrls.npsa.nhs.uk/resources/pati ent-safety-topics/risk-assessmentmanagement

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Ethiopia Public Health Training Initiative: Health Learning Materials

The Ethiopia Public Health Training Initiative aims to develop learning materials based on the Ethiopian experience, to ensure that pre-service training is directly relevant to the country's health practices and priorities.

http://www.cartercenter.org/health/ephti /learning_materials/index.html

Foresight Range (NPSA)

The Foresight Training resource pack aims to help pre- and post-registration nurses and midwives develop and practise the skills needed to identify situations when a patient safety incident is more likely to occur. Foresight is the ability to identify, respond to and recover from the initial indications that a patient safety incident could take place. Foresight Training consists of scenarios relevant to staff in primary care, acute care and mental healthcare settings. The scenarios are both paper- and video-based, and supported by materials for a training facilitator. The range comprises: resource packs for trainers; presentation slides; scenarios; examples of the Three Buckets Model; background information; glossary and reading material and handouts.

The documents were created by Ethiopians, for Ethiopians. Use of the materials is encouraged for individuals or organizations who desire to view one model of how to build the capacity to provide pre-service health education for a particular population of healthcare workers. Developed for the English NHS in 2008 the underlying principles behind these resources can be applied in many settings and the training can be adapted for use by other healthcare professionals.


Access background information, videos and the Foresight Training Resource Packs at : http://www.nrls.npsa.nhs.uk/resources/ patient-safety-topics/human-factorspatient-safety-culture/?entryid45=59840

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Purpose


Where to find

H1N1 Checklist

The WHO Pandemic (H1N1) 2009 patient care checklist is intended for use by hospital staff treating a patient with a medically suspected or confirmed case of Pandemic (H1N1) 2009. This checklist combines two aspects of care: i) clinical management of the individual patient and ii) infection control measures to limit the spread of Pandemic (H1N1) 2009.

The checklist is not intended to be comprehensive. Additions and modifications to fit local practice and circumstances are encouraged.

Access the checklist: http://www.who.int/patientsafety/implem entation/ah1n1_checklist/en/index.html

Developed for the English NHS the resource is based on a comprehensive literature review and has the potential to be of value for anyone considering implementing changes in health care. Real life examples are provided illustrating how the methods described have brought about positive changes in a range of situations.

NICE homepage: http://www.nice.org.uk/ Access the resource: http://www.nice.org.uk/media/D33/8D/H owtochangepractice1.pdf

Developed for the English NHS the guide offers a series of practical steps designed to assist with implementing guidelines.

NICE homepage: http://www.nice.org.uk/

How to Change Practice: Understand, Identify and Overcome Barriers to Change (NICE)

This 48 page guide aims to help managers and clinicians influence changes in practice, and accompanies the ‘How to put NICE guidance into practice’ launched in December 2005. ‘How to change practice: Understand, identify and overcome barriers to change’ provides practical suggestions based on evidence and experience to help get NICE guidance into practice. The guide is split into 3 parts:

Case study page no.

 Part 1 discusses the types of barriers to change encountered in healthcare.  Part 2 offers practical suggestions for how to identify the barriers to changes in your organisation.  Part 3 shows how to overcome these barriers, and highlights potential levers to help people do this. How to put NICE Guidelines into Practice (NICE)

This 49 page guide to implementation, issues in 2005 by the UK National Institute for Health and Clinical Excellence aims to help organisations  implement NICE guidance and other national policy

Access the guide to implementation at: http://www.nice.org.uk/media/848/D0/H owtoputNICEguidanceintopracticeFINA L.pdf

 comply with core and developmental standards set in Standards for better


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Purpose


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health  meet the Healthcare Commission’s expectations The guide is split into three parts – the first two focuses on organisations directly responsible for implementation, and the third focuses on commissioning organisations. Incident Decision Tree (NPSA)

This resource is concerned with moving from a culture which asks “Who was to blame?” to asking “Why did the individual act in this way?” when things go wrong. The Incident Decision Tree has been created to help NHS managers and senior clinicians decide whether they need to suspend (exclude) staff involved in a serious patient safety incident and to identify appropriate management action. The aim is to promote fair and consistent staff treatment within and between healthcare organisations.

The Incident Decision Tree is a webbased tool and is described as simple to use, not requiring any special computer skills. The Incident Decision Tree complements the NPSA’s Root Cause Analysis Toolkit and the two can be used in parallel. Created for the NHS in the UK and utility has not been tested outside of this setting.

http://www.npsa.nhs.uk/nrls/improvingp atientsafety/patient-safety-tools-andguidance/incidentdecisiontree/

Knowledge Management toolkit (SDC)

The Toolkit features a selection of more than 20 methods and tools for knowledge sharing and learning including: Balanced Scorecard; Knowledge Network; After Action Review and Community of Practice. These are intended to be applied at a personal, team and organizational level. The video was produced for use in a seminar or workshop setting in conjunction with the Learning from Error booklet. The booklet explains more about how the resource can be used to facilitate learning for health care professionals.

The aim of the toolkit is to help in the selection and application of methods for planning and reflecting on activities and to draw lessons and share insights. The toolkit is available in English with a shorter reference version available in French.

To access SDC knowledge Management resources: www.daretoshare.ch To access this toolkit: http://www.daretoshare.ch/en/Dare_To _Share/Knowledge_Management_Meth ods_and_Tools/media/Comprehensive %20Brochure/Broschüre%20KM%20To olkit.pdf To access the videos and booklet and request hard copies of the resources in both French and English go to: http://www.who.int/patientsafety/educati on/vincristine_download/en/index.html

Learning from Error – video and booklet (WHO)

Video files can be downloaded to view on a p.c. and are available in wmv format.


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National Electronic Library for infection (NELI)

National resource for Infection Control (NRIC)

Pareto (NHSI)

Patient Safety and Quality

Purpose

Chapter 1 provides an introduction to the concept of root cause analysis. Chapter 2 is a dramatized incident of how a series of errors led to the incorrect administration of vincristine. Chapters 3-8 analyse the drama in the light of five factors that can reduce error in health care. NeLI is a digital library bringing together the best available on-line evidencebased, quality-tagged resources on the investigation, treatment, prevention and control of infectious disease. NRIC is a project developed by healthcare professionals, aimed at being a single-access point to existing resources within infection control for both Infection Control and all other healthcare staff. NRIC is supported by the UK Department of Health and City University, London.

One of the NHSI suite of quality improvement tools, the Pareto analysis is a simple technique that helps organizations focus efforts on the problems that offer the greatest potential for improvement by showing their relative frequency or size in a descending bar graph. Pareto's principle, the 80/20 rule, is concerned with focusing 80 per cent of available time and energy on the 20 per cent that really makes a difference. The AHRQ Quality Indicators (QIs)


Where to find

Case study page no.

This is connected to the National Resource for Infection Control – a potentially useful portal for accessing a range of infection prevention resources.

Access the library: http://www.neli.org.uk/IntegratedCRD.n sf/NeLI_Home1?OpenForm

The electronic resource enables the user to access resources related to infection control in a number of ways – searches can be undertaken alphabetically, by health care setting speciality, by clinical practice category, by route of transmission, by disease/organism and by policy/guidance. Users are presented with the title of the resource, the type of resource, the level of evidence associated with the resource, its source and publication date. Each resource is reviewed providing the user with comprehensive information on its utility. This tool will help to rapidly identify the major causes of a problem so that resources can be focused on the cause of those issues with the most potential for improvement.

To access NRIC: http://www.nric.org.uk/IntegratedCRD.n sf/NRIC_Home1?OpenForm

http://www.institute.nhs.uk/quality_and_ service_improvement_tools/quality_and _service_improvement_tools/pareto.ht ml

*To use this resource you need to create an account

The PSIs were developed after a


Access the AHRQ complete range of Page 48 of 117


Purpose


Where to find

Indicators (AHRQ)

measure health care quality by using readily available hospital inpatient administrative data. The Patient Safety Indicators (PSIs) are a tool to help health system leaders identify potential adverse events occurring during hospitalization. The PSIs are a set of indicators providing information on potential in hospital complications and adverse events following surgeries, procedures, and childbirth.

comprehensive literature review, analysis of ICD-9-CM codes, review by a clinician panel, implementation of risk adjustment, and empirical analyses.

resources at: http://www.ahrq.gov/qual/pstools.htm Access this resource at: http://www.qualityindicators.ahrq.gov/m odules/psi_overview.aspx Link changed 10/12/2011

Patient Safety Curriculum Materials (WHO)

The curriculum is intended as a guide for undergraduate medical education to provide a foundation for patient safety for medical students. It is not intended for clinicians.

Curriculum may also be used by nursing, midwifery, pharmacy, dentistry, etc (undergraduate education)

Patient Safety Research: A guide for developing training programmes

Based on extensive consultation with key international experts in education and training, this comprehensive tool provides practical guidance for educators to develop training programmes in the field of patient safety research.

Patient Safety Research: Introductory course (on-line) (WHO)

This new, free on-line course starts in April 2010 to introduce the basic elements of Patient Safety Research. It is intended to assist in understanding the magnitude of the problem in hospitals and primary care facilities as

The guide brings current concepts on curriculum building, as well as training and education to the field of patient safety research. It is designed to offer practical guidance to local educators developing their own training programmes – in accordance with their context-specific learning objectives. A key feature of this guide is the outline of the core skill and knowledge-based competencies that professionals at various levels of expertise may wish to acquire to conduct effective patient safety research and improvement efforts. All sessions will be broadcasted through the RAFT network (RAFT:Réseau en Afrique Francophone pour la Télémédecine) developed by the Geneva University Hospitals (HUG) in 2000 as well as with

The PSIs are a software tool distributed free by AHRQ. The software can be used to help hospitals identify potential adverse events that might need further study. The PSI software programs can be applied to any hospital inpatient administrative data.


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For general information on patient safety training and education: http://www.who.int/patientsafety/educati on/en/ For the Patient Safety Curriculum Guide: http://www.who.int/patientsafety/educati on/curriculum/en/index.html http://www.who.int/patientsafety/en.

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Purpose


a first step towards improving Patient Safety. The sessions will be provided by internationally renowned specialists in Patient Safety; Dr David Bates, External Program Lead for Research, WHO Patient Safety, and the Director of the Center of Excellence in Patient Safety and Research in USA, and Dr Albert Wu, a professor in the Department of Health Policy and Management at Johns Hopkins University, USA.

the application, GoToWebinar. French sessions will be launched in the near future. (sessions en français seront lancés dans un proche avenir).

Where to find

Case study page no.

To follow the course, please click the URL listed in column 4. Participants need a computer with internet access and functioning speakers. One computer per group is also no problem. There's no need to install any new applications on the computer. Weekly sessions commence April 2010 through to May 2010.

Patient Safety Solutions

Nine patient safety solutions to reduce the toll of health care-related harm affecting millions of patients daily, worldwide, were launched on 2 May 2007, by the World Health Organization (WHO)

The nine solutions are based on interventions and actions that have addressed patient safety problems in some countries. They are now being made available in an accessible form for use and adaptation by WHO Member States to re-design patient care processes and to make them safer.

Peoples Open Access Education Initiative: Peoples-uni

Peoples-uni aims to help with Public Health capacity building in low- to middle-income countries, through Internet based education.

The use of Open Educational Resources freely available on the Internet, and volunteers to staff the Initiative, allows this to be offered at very low cost 30GBP per course


Main link : http://www.who.int/patientsafety/events/ 07/02_05_2007/en/index.html Link to -Patient safety solutions preamble- May 2007 http://www.who.int/patientsafety/solutio ns/patientsafety/Preamble.pdf -Look-Alike, Sound-Alike Medication Names http://www.who.int/patientsafety/solutio ns/patientsafety/PS-Solution1.pdf -Patient Identification http://www.who.int/patientsafety/solutio ns/patientsafety/PS-Solution2.pdf Communication During Patient HandOver http://www.who.int/patientsafety/solutio ns/patientsafety/PS-Solution3.pdf For further information and enrolment information: http://www.peoples-uni.org/

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Purpose


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module. Modules offered twice a year - cover the Foundations Sciences of Public Health and Public Health problems.

Practical Handbook for Clinical Audit by Clinical Governance Support Team, 2005 (NHS)

Principles of Best Practise in Clinical Audit (NHS)

This is a guidance document published by the Clinical Governance Support team, NHS which describes ways to improve clinical audit in health care facilities including types of clinical audit, required resources, action plan, developing audit cycles etc. Specifically illustrates models of clinical audit which can be applied at local level. List of annexes at the end provide users with tools for clinical audit such as Self Assessment Tool, patient involvement and Tools to monitor Compliance with NICE Guidelines. This document prepared by the National Institute of Clinical Excellence (NICE) with other key partners, outlines key principles in conducting clinical audit. The document focuses on creating the local environment for audit and outlines key audit methods that are most likely to lead to audit projects that result in improvements. A range of audit resources are found in the appendices including a glossary

Peoples-uni functions through the use of volunteer international faculty to develop modules and guide online discussions. It encourages partnerships and collaboration across the global and digital divides. Certificate and Diploma awards are attained on completion of the courses. Primarily developed for Acute care trusts, Primary care Trusts and Mental Health Care Trusts, NHS, hence its applicability for different health systems needs to be considered.

A systematic and practical five step approach to utilizing clinical audit methodology in health care institutions.

http://www.hqip.org.uk/assets/Dow nloads/Practical-Clinical-AuditHandbook-CGSupport.pdf

http://www.nice.org.uk/media/796/23/B estPracticeClinicalAudit.pdf

Challenge: NHS focussed, Applicability in low resource settings need to be considered


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Action Area 3: Knowledge and Learning in Patient Safety RAFT Network

Purpose

and a list of online resources on clinical audit. Initially set up to provide telemedicine to francophone countries in West Africa. Distance continuing education seminars for Africa; 8 1-hour seminars covering science of patient safety, research, and how to translate research into practice. Teleconsultation tool enables virtual communities of care professionals to exchange advice about the management of clinical cases.

Reporting & Learning Guidelines (WHO)

To help countries develop or improve reporting and learning systems in order to improve the safety of patient care

Root Cause Analysis Range (NPSA)

The RCA range comprises an online toolkit developed in 2004, and is designed to enable the user to:  understand what an RCA investigation is  develop appropriate knowledge and skill to play a part in an RCA investigation  develop a causal-based approach to the analysis of issues and problems that threaten patient safety, rather than one of blame. The toolkit is accompanied by a range of report writing tools and templates comprised of: Report template guidance; Guide to investigation report writing; sample reports; Evaluation, checklist, tracking and learning log; Triggers for RCA investigation;


Where to find

Case study page no.

Available with low bandwidth therefore able to reach more remote areas. This is a tool to educate researchers about patient safety. And creates opportunities for bidirectional knowledge transfer. In terms of challenges:  Unable to use more sophisticated tools (e.g. videos) due to low bandwidth.  Technology issues (internet access). Requires reliable source of electricity.  Program primarily for francophone countries. Guidelines could serve as roadmap for implementation of monitoring systems In terms of challenges: Guideline revision is pending.

http://raft.hcuge.ch/

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The toolkit was developed for use in the English NHS.

To access the RCA toolkit; http://www.nrls.npsa.nhs.uk/resources/ patient-safety-topics/human-factorspatient-safetyculture/?entryid45=59901&p=3


http://raftadmin.blogspot.com/

http://www.who.int/patientsafety/events/ 05/Reporting_Guidelines.pdf

To access a range of report writing tools and templates: http://www.nrls.npsa.nhs.uk/resources/ ?entryid45=59847

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Safe Surgery Checklist (WHO)

Unmet Needs: Teaching Physicians to Provide Safe Patient Care (NPSF)

WHO-AFROLIB

Purpose

Guidance on the three levels of investigation; Investigative interview guidance and a Guide to aggregated and multicentre RCA investigations.  To reduce the rate of major surgical complications  To reinforce accepted safety practices and ensure that they are followed in order to minimize common, avoidable risks to surgical patients  To foster better communication and teamwork between surgeons, anesthesia professionals, nurses, technicians and other operating room personnel This report is the culmination of three Lucian Leape Institute Roundtable discussions which makes key recommendations for reforming medical education in order to improve patient safety. The paper is the first in a planned series of such reports on issues that the Lucian Leape Institute has identified as top priorities in ongoing efforts to improve patient safety. A number of web links on Patient Safety knowledge and learning resources can be found by navigating through WHO-AFROLIB (please go to internet link )


Where to find

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 Simple, easy to use;  Can be modified for use in specific settings;  Low cost to implement;  Can be implemented quickly (within 1 month); In terms of challenges:  Pulse oximetry required  Adequate access to antibiotics required.

http://www.who.int/patientsafety/safesur gery/en/index.html

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http://www.safesurg.org

Access this resource: http://www.npsf.org/wpcontent/uploads/2011/10/LLI-UnmetNeeds-Report.pdf

A comprehensive resource of books and journals on a range of topics relevant to strengthening patient safety


Access to WHO- AFROLIB: http://afrolib.afro.who.int/Infodigest/info dig/infodg.html This leads to links such as: -Health Sciences online at http://hso.info/hso/cgi-bin/querymeta?v%3aframe=form&frontpage=1&v %3aproject=HSO& (this is a search engine that contains several resources on PS). -HINARI (Research in health) http://www.who.int/hinari/about/en/ (Registration on this website is beneficial to the user) -AFRICAN INDEX MEDICAL JOURNALS

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http://indexmedicus.afro.who.int/Journal s/Indexj.htm -HEALTHY CHILD UGANDA HCU CORPs MANUAL http://www.healthychilduganda.org/assets/U ploads/CorpsManualTIF.pdf TRAINERS MANUAL

http://www.healthychilduganda.org/ass ets/Uploads/HCU%20Trainers-ManualJune-06.pdf


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Action Area 4: Patient Safety Awareness Raising Action Area 4: Patient Safety Awareness Raising

Purpose


Where to find


This revised guidance on communicating effectively with patients when things go wrong is a best practice guide for all healthcare staff, including boards, clinicians and patient advocates. It explains the principles behind Being open and outlines how to communicate with patients, their families and carers following harm. This guidance and the associated actions outlined in an accompanying Alert, provide reassurance that Being open is the right thing to do, and encourage NHS boards to make a public commitment to openness, honesty and transparency. The full range of tools include: Webinars for clinicians; Webinars for Board members; an Alert; Supporting Information; a Framework and an elearning module. The cleanyourhands campaign was the first nationally coordinated and funded promotional campaign, aimed at improving hand hygiene of healthcare workers. It employed a multifaceted approach and relied on social marketing principles to begin about behaviour change of front-line workers.

The resource is connected to the national drive in the UK to assist health care staff when things go wrong.

Access the entire range at: http://www.nrls.npsa.nhs.uk/resources /?entryid45=65077

The campaign has been independently evaluated by a team of researchers and has demonstrated evidence of impact on the prevention of health care-associated infection.

To access the main website: http://www.npsa.nhs.uk/cleanyourhan ds/

Engaging Clinicians is a resource pack, published in 2002, to help promote patient safety and the reporting of incidents amongst healthcare staff in training. It aims to help NHS staff raise

The resource pack is modular. Each module lasts about 90 minutes and modules can be taken separately or together. The pack contains a variety of resources and examples of ways in which NHS organisations around the

Access Engaging Clinicians: http://www.nrls.npsa.nhs.uk/resources /?EntryId45=59883

cleanyourhands campaign (NPSA)

Engaging Clinicians range (NPSA)


Case study page no.

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Five Million Lives Campaign (IHI)


Purpose


awareness in their organisation about:  Patient safety;  The importance of reporting incidents;  The benefits of sharing resources to improve patient safety. It can be used by risk managers, clinical governance managers, training managers and ward or department managers in any healthcare setting. It may also be used by other healthcare staff with responsibility for, or an interest in, developing the skills, knowledge and awareness of patient safety amongst healthcare professionals. It is accompanied by a CD and compendium of case studies. Building on the IHI 100,000 Lives Campaign, the 5 Million Lives Campaign was launched in 2006 with the aim to prevent 5 million incidents of medical harm within the US health system over a 2 year period. The campaign recommended 12 interventions designed to reduce harm. Hospitals were invited to focus on at least one intervention. Ask Me 3 is a patient education program designed to promote communication between health care providers and patients in order to improve health outcomes. The program encourages patients to understand the answers to three questions: 1. What is my main problem? 2. What do I need to do? 3. Why is it important for me to do this?

country have raised awareness of patient safety. Developed for the NHS, generic templates found in the pack can be customised with local examples to raise awareness of patient safety amongst all staff groups

Where to find

The campaign site provides access to a range of resources, How To Guides, presentations and a general campaign resource guide. Material is freely available.

Access the main IHI 5 Million Lives Campaign website: http://www.ihi.org/IHI/Programs/Camp aign/Campaign.htm?TabId=2&player= wmp

Developed by the US National Patient Safety Foundation

To access general information: http://www.npsf.org/askme3/index.ph p To access the resources in English and Spanish: http://www.npsf.org/for-healthcareprofessionals/programs/ask-me3/ask-me-3-resources/

Case study page no.

The series consists of a range of education resources in the form of


Page 56 of 117

Action Area 4: Patient Safety Awareness Raising Patients for Patient Safety: Jakarta Declaration (WHO)

Patients for Patient Safety: London Declaration (WHO)

Patients for Patient Safety Workshops (WHO)

Patient Safety and Quality: An Evidence based Handbook for Nurses (AHRQ)

Purpose

leaflets, brochures, posters and an implementation guide The Jakarta Declaration serves as a call to action for all parties to work in partnership to improve patient safety. The Declaration is a call for change, openness, honesty, transparency.

The London Declaration is a tool developed by patients with experience of negative outcomes associated with medical error. It serves as a call to action for all parties to work in partnership to improve patient safety. The Declaration is a call for change, openness, honesty, transparency. The reports outline the importance of workshops as a vehicle for awareness raising and a contributor to the formation of partnerships between patients, physicians, government, to collectively address patient safety issues. The workshops further provide an opportunity for modelling of actions for patients who have experienced bad outcomes.

This resource is intended to assist nurses in their vital role in improving the safety and quality of patient care. It describes proven techniques and interventions they can use to enhance


Where to find

The Declaration provides a template example of partnership formation.

Main page for declarations: http://www.who.int/patientsafety/patie nts_for_patient/resources/en/index.ht ml Jakarta declaration PDF: http://www.who.int/patientsafety/patie nts_for_patient/jakarta_declaration.pd f

The Declaration provides a template example of partnership formation. It opens the door for dialogue between different parties.

Main page for declarations: http://www.who.int/patientsafety/patie nts_for_patient/resources/en/index.ht ml London Declaration PDF: http://www.who.int/patientsafety/patie nts_for_patient/London_Declaration_ EN.pdf

The workshops provide an opportunity to break down barriers so that patients, providers and Ministries of Health can work together to improve patient safety. The workshop model can be replicated at the national level and the reports have utility in providing ideas and preventing wheel reinvention. It is important to note that medical error is a sensitive topic, difficult to discuss in public setting with multiple parties present (patients, providers, Ministries of Health) and so a workshop may not be suitable for all contexts. This comprehensive, 1,400-page, handbook for nurses on patient safety and quality has been compiled by experts in the field following a review of the literature. It is grouped into sections: Patient Safety and Quality / Evidence-based Practice / Patient-

http://www.who.int/patientsafety/patie nts_for_patient/workshops/en/index.ht ml


Case study page no.

111

Access the AHRQ complete range of resources at: http://www.ahrq.gov/qual/pstools.htm Access this resource at: http://www.ahrq.gov/qual/nurseshdbk/ nurseshdbk.pdf

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Purpose


patient outcomes.

centered Care / Working Conditions— Work Environment / Critical Opportunities for Patient Safety and Quality / Tools. The entire volume can be downloaded free of charge as a PDF (10 MB) or individual chapters can be downloaded. • Existing network of patient safety champions can be utilized to create a broader social network • Social network is a valuable tool for education and for dissemination of information • Use Patient Safety Champions as a vehicle for improving patient safety awareness among patients, and for achieving community engagement • Promotes awareness of patient safety among patients/consumers • Use of personal stories makes patient safety issues more concrete, and may be useful in changing behaviour • Tool for achieving community engagement In terms of challenges: • Participation requires attendance at Patient Safety Workshop • PS Champions may need to be from local community to be effective

Patient Safety Champions (WHO)

• Raise patient safety awareness • Form partnerships between patients, physicians, government, to collectively address patient safety issues • Opportunity for modeling of actions for patients who have experienced bad outcomes

Patient Safety First Campaign (NPSA; NHSI; The Health Foundation)

Patient Safety First is a campaign sponsored by the National Patient Safety Agency, the NHS Institute for Innovation and Improvement and The Health Foundation. The campaign, which is underpinned by improvement methodology, has been developed by a team of clinicians and managers experienced in patient safety. It consists of a range of materials to assist with implementation and

The campaign is designed for the UK health care system. Useful campaign materials include a:  Quick Guide to Implementing Improvement (13 pages)  How to Guide for Implementing Human Factors in Health Care  Guide to Communication  Templates for letters


Where to find

Case study page no.

To see a list of all Champions and details of champions across the WHO regions: http://www.who.int/patientsafety/patie nts_for_patient/regional_champions/e n/index.html

111

 General campaign website: http://www.patientsafetyfirst.nhs.uk/ content.aspx?path=/  A PDF of the Quick Guide to Implementing Improvement is available at: http://www.patientsafetyfirst.nhs.uk/ ashx/Asset.ashx?path=/How-toguides-2008-0919/Quick%20Guide%201.1_17sept 08.pdf Page 58 of 117


Purpose


evaluation. The campaign interventions are:  Leadership for safety;  Care of the deteriorating patient;  Critical care: central line and ventilator bundles;  Perioperative care: surgical site infection bundle and WHO Safe Surgery Checklist  Reduction of harm from high risk medication

Patient Voices Videos (WHO)

• Raise awareness and knowledge of patient safety • Model proactive behaviour for patients who have experienced poor outcomes due to medical error • Promoting partnerships to address patient safety issues

Speak Up Initiatives for Patients (JC)

These resources form part of the Joint Commission national campaign to urge patients to take a role in preventing health care errors by becoming active, involved and informed participants on the health care team. Heath care organizations have reported printing Speak Up materials in patient rooms; sponsoring local

• Puts an individual/human face onto patient safety problems • Individual stories are a powerful motivating tool • Takes advantage of adult learning model to engage audience (intersperse videos with lectures) In terms of challenges: • Technology issues (e.g. no video player) • Hard to track effect of videos (wide distribution) The program features brochures, posters and buttons on a variety of patient safety topics. Organizations can download and print as many copies as they would like to distribute to patients, staff and community members. The brochures include a blank panel for organizations to insert their own patient safety information, logo and


Where to find  A PDF of the How to Guide for Implementing Human Factors in Health Care: http://www.patientsafetyfirst.nhs.uk/ ashx/Asset.ashx?path=/Intervention support/Human%20Factors%20Ho w-to%20Guide%20v1.2.pdf  A PDF of the Guide to Communication: http://www.patientsafetyfirst.nhs.uk/ ashx/Asset.ashx?path=/supportmaterials/A%20Guide%20to%20Co mmunicating%20the%20Patient%2 0Safety%20First%20campaign%20f or%20England%20v2.pdf  A PDF letter template is available at: http://www.patientsafetyfirst.nhs.uk/ ashx/Asset.ashx?path=/GettingStarted/Sign%20Up%20Form.pdf To access the video of patient voices and a range of other advocacy materials including speeches and interviews with patient champions: http://www.who.int/patientsafety/patie nts_for_patient/videos/en/index.html

Case study page no.

111

To access this resource: http://www.jointcommission.org/speak up.aspx

Page 59 of 117


Statement of Case – Patients for Patient Safety (WHO) Twenty Tips to help prevent Medical Errors: Patient Fact sheet (AHRQ)

What you can do to make Health Care Safer: A Consumer Fact sheet (NPSF)

Purpose


public service announcements; including Speak Up content in patient information materials, websites and community newsletters; distributing material at health fairs; sharing it on closed circuit patient education television; using it for staff education and orientation. • Goal to make case that Patients for Patient Safety needed to be part of movement to improve patient safety Patient fact sheet outlining the top tips for making health care safer for patients and the public.

contact information.

• When woven into patient stories (e.g. in videos), makes stories more powerful

Encourages patient involvement in their treatment and the importance of patients receiving information. Outlines a series of steps which consumers can undertake to make sure they have a safer experience with the health care system.


Where to find

Case study page no.

http://www.who.int/patientsafety/patie nts_for_patient/statement/en/index.ht ml Access the AHRQ complete range of resources at: http://www.ahrq.gov/qual/pstools.htm Access this resource at: http://www.ahrq.gov/consumer/20tips. pdf http://www.npsf.org/for-patientsconsumers/tools-and-resources-forpatients-and-consumers/what-youcan-do-to-make-healthcare-safer/

Page 60 of 117

Action Area 5: Healthcare-Associated Infections Action Area 5: Health care-associated Infections

Purpose

A Compendium of Strategies to Prevent HealthcareAssociated Infection in Acute Care Hospitals (SHEA)

The compendium of strategies to prevent health care-associated infection has been developed to provide a concise, evidence based resource containing practical recommendations for acute care hospitals. The aim is to promote uniform implementation of basic infection surveillance, control, and prevention recommendations in all acute care hospitals in the United States which will lead to improvements in hospitals’ infection rates and patient safety programs. Developed by WHO’s Global Alert and Response unit these guidelines provide a comprehensive introduction to infection prevention and control. The information is intended to assist administrators, infection control personnel, and patient care workers in facilities with limited resources in the initial development of a nosocomial infection control programme, including specific components of such programmes.

A Practical Guide on the Prevention of Nosocomial nd Infections (2 edition) 2008 (WHO)

Basic Concepts of Infection Control (IFIC)

This book is authored by experts in infection prevention and control, microbiology, and epidemiology. The intent of the book is to provide a foundation of scientifically basic infection prevention and control principles and requirements.

Center for disease control

Bloodstream infections in patients with


Where to find

Case study page no.

Access the full document and its individual sections: http://www.sheaonline.org/about/compendium.cfm

This manual has been developed to be a practical, basic, resource which may be used by individuals with an interest in nosocomial infections and their control, as well as those who work in nosocomial infection control in health care facilities. It is applicable to all facilities, but attempts to provide rational and attainable recommendations for facilities with relatively limited resources. Additional reading in specific areas is provided in the list of WHO relevant documents and infection control texts at the end of the manual. The advantage of this book is that it is not connected to any country's legal regulations or traditions and therefore it transcends national boundaries. One copy of each of the chapters in this book can be freely downloaded for personal use, together with the accompanying teaching slides. Medical professionals have reduced


English version of the Guide: http://www.who.int/csr/resources/publi cations/whocdscsreph200212.pdf

French version of the Guide: http://www.who.int/csr/resources/publi cations/WHO_CDS_CSR_EPH_2002. 12fr.pdf

Access the IFIC home page: http://www.theific.org/ Access this resource: http://www.theific.org/basic_concepts/i ndex.htm Refreshed 10/2011

http://www.cdc.gov/vitalsigns/hai/inde

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Action Area 5: Health care-associated Infections

Purpose


Where to find

and prevention Making Healthcare Safer: Reducing Bloodstream Infections

central lines are largely preventable when healthcare providers use CDCrecommended infection control steps.

x.html

Clean Safe Care (Department of Health UK)

The Clean Safe Care website is a resource for UK healthcare staff. The purpose of the resource is to provide a hub for information, tools and news about reducing healthcare associated infections and providing safe, clean, reliable healthcare in the NHS.

cleanyourhands improvement strategy and toolkit (NPSA)

The cleanyourhands campaign aims to improve the hand hygiene of healthcare staff at the point of patient/service user care. It was developed by the National Patient Safety Agency (NPSA) to help the NHS in England and Wales to reduce healthcare associated infection (HCAI). The campaign is focused on

these infections in hospital intensive care unit (ICU) patients by 58% since 2001. Even so, many still occur in ICUs, in other parts of hospitals, and in outpatient care locations. In 2008, about 37,000 bloodstream infections occurred in hemodialysis* outpatients with central lines. The tools within the Saving Lives programme provide a framework to healthcare workers in the achievement of high quality care. The approach of Clean Safe Care (and the associated Saving Lives tools) is based on safety and reliability. The website provides access to a wealth of tools and resources, some of which are listed below:  High impact intervention guidance on central venous catheter care; peripheral intravenous catheter care; renal dialysis catheter care; prevention of surgical site infection; care for ventilated patients; urinary catheter care; reducing risks of Clostridium difficile and cleaning and decontamination of clinical equipment.  Self-assessment tools,  Productivity calculators,  Training resources, The strategy is based around:  Promotion of alcohol handrub at the point of care and appropriate use of soap and water.  Posters and other materials to raise awareness and prompt hand hygiene by staff  Involving patients in improving the hand hygiene of healthcare


Case study page no.

To access the general Clean Safe Care site: http://webarchive.nationalarchives.gov .uk/20120118164404/hcai.dh.gov.uk/i ndex.php

111

To access the main cleanyourhands website: http://www.npsa.nhs.uk/cleanyourhan ds/

Page 62 of 117


Purpose

hand hygiene at the point of care. The campaign employs a multimodal strategy to educate, prompt and enable healthcare staff to perform hand hygiene at the right moments, every time during the care of patients/service users. Core Components for Infection Control Programmes (WHO)

The Core Components for Infection Prevention and Control Programme paper produced by WHO in 2008 identifies those components of an infection control programme which are considered as essential and “of the utmost importance, being basic, indispensable and necessary for any IPC programme to meet its objectives”. The core components are constructed around Organization of IPC programmes; Technical guidelines; Human resources; Surveillance of infections and assessment of compliance with IPC practices; Microbiology laboratory; Environment; Monitor and evaluation of programmes; Links with public health or other services.


workers Guidance and resources to support local implementation, training, promotion and engagement. The campaign materials, guidance and resources are provided free-ofcharge to NHS trusts. The core components have particular relevance to resource poor settings and provide a robust framework for exploring the essentials of infection prevention and control.

Where to find

Case study page no.




http://whqlibdoc.who.int/hq/2009/WHO _HSE_EPR_2009.1_eng.pdf

Page 63 of 117


Purpose


Where to find

Getting Started: Reducing MRSA infection, How to Guide (IHI Five Million Lives Campaign)

The goal of this guide is to significantly reduce methicillinresistant Staphylococcus aureus (MRSA) transmission and infection by reliably implementing five components of care recommended in the Guide: Hand hygiene; Decontamination of the environment and equipment; Active surveillance; Contact precautions for infected and colonized patients and device bundles (Central Line Bundle and Ventilator Bundle).

Provides some useful examples and a model for how to start the process of tackling resistant organisms in health care.

Access this resource:

Guidance on Uniforms and work wear (RCN)

This updated guidance sets out information on issues related to the selection, wearing and decontamination of uniforms or clothing worn in the delivery of patient care and is aimed at nurses and their employers. It can be applied to all settings in which health care takes place and for any clothing worn when undertaking patient care activities. The Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008, presents evidence-based recommendations on the preferred methods for cleaning, disinfection and sterilization of patient-care medical devices and for cleaning and disinfecting the healthcare environment. This 225 page updated guideline responds to changes in healthcare delivery and addresses new concerns about transmission of infectious agents to patients and healthcare workers and infection control. The primary objective of the guideline is to improve the safety of healthcare

This document provides suggested content for uniform and work wear policy/guidance.

To access the general RCN infection prevention page: http://www.rcn.org.uk/development/pr actice/infection_control To access this resource: http://www.rcn.org.uk/__data/assets/p df_file/0010/78652/002724.pdf

A comprehensive account (158 pages) of all aspects of disinfection and sterilization. Including a review of multiple cleaning and disinfection agents. Heavily weighted to the US health care system.

Access the CDC website at: http://www.cdc.gov/ Access the full version of the Guideline at http://www.cdc.gov/ncidod/dhqp/pdf/g uidelines/Disinfection_Nov_2008.pdf

The guideline is designed for use within the US health care context by individuals who are charged with administering infection control programs in hospitals and other healthcare settings. The information is also intended to be useful for other healthcare personnel, healthcare

Access the CDC website at: http://www.cdc.gov/ Access the full version of the Guideline at http://www.cdc.gov/ncidod/dhqp/pdf/g uidelines/Isolation2007.pdf

Guideline for Disinfection and Sterilization in Health Care Facilities (CDC)

Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (CDC)


Case study page no.

http://www.saferhealthcarenow.ca/ EN/Interventions/Superbugs/Docu ments/ARO%20MRSA%20Getting %20Started%20Kit.pdf

Page 64 of 117


Guidelines for Prevention of Catheter Associated Urinary Tract Infections (CDC/HICPAC)

Guidelines for Prevention of TB in resource limited

Purpose


delivery systems by reducing the rates of HAIs. The objectives of the guideline are stated as: 1) provide infection control recommendations for all components of the US healthcare delivery system; 2) reaffirm Standard Precautions as the foundation for preventing transmission during patient care in all healthcare settings; 3) reaffirm the importance of implementing Transmission-Based Precautions based on the clinical presentation or syndrome and likely pathogens until the infectious aetiology has been determined; and 4) provide epidemiologically sound and, whenever possible, evidence-based recommendations. This updated guideline includes new research and technological advancements for preventing CAUTI. It places emphasis on prevention initiatives and better defined goals and metrics for outcomes and process measures. The guideline also reviews the available evidence on CAUTI prevention for patients requiring chronic indwelling catheters and individuals who can be managed with alternative methods of urinary drainage (e.g., intermittent catheterization.

administrators, and anyone needing information about infection control measures to prevent transmission of infectious agents.

These guidelines published in 1999, provide discussion and

These comprehensive guidelines are the result of a systematic review of the literature up to 2007. In addition to presenting the evidence the guidelines also include specific recommendations for implementation, performance measurement, and surveillance, outlining high-priority recommendations for CAUTI prevention. They are intended for use by infection prevention staff, healthcare epidemiologists, healthcare administrators, nurses, other healthcare providers, and persons responsible for developing, implementing, and evaluating infection prevention and control programs for healthcare settings across the continuum of care. WHO state that these guidelines provide cost effective interventions


Where to find

Case study page no.

Access the CDC website at: http://www.cdc.gov/ Access the full version of the Guideline at http://www.cdc.gov/ncidod/dhqp/pdf/g uidelines/CAUTI_Guideline2009final.p df

Access the guidelines: http://www.who.int/tb/publications/who

Page 65 of 117


Purpose


Where to find

settings

recommendations for the district and referral level (thus accounting for the wide variety of health care facilities) based upon three levels of infection control: administrative, environmental, and personal respiratory protection.

_tb_99_269.pdf


 Provide healthcare workers, hospital administrators and health authorities with a review of evidence on hand hygiene in health care  To provide specific recommendations to improve hand hygiene practices and reduce healthcare associated infections This document forms part of the WHO Regional Office for Africa’s work in collaboration with the Centers for Disease Control and Prevention (CDC), USA and other partners is developing a regional strategy to strengthen national public health laboratories (NPHL). A particular emphasis is placed on providing laboratory data for high priority bacterial diseases including cholera, dysentery, meningitis and plague.

that can be directly implemented (or modified) within a facility at the district or referral level in any resource-limited setting. Efforts should be made to execute such control strategies to prevent nosocomial transmission of M. tuberculosis. Such measures serve not only to conserve resources in terms of direct costs due to treatment of healthcare workers and indirect costs in terms of loss of healthcare workers specialising in the management of TB patients, but also in reducing the burden due to tuberculosis. Tools can be adapted according to local needs.

This guide is intended for the national ministry of health (MoH) laboratory focal point or chief officer who oversees all the laboratories in the country, the coordinator of the NPHLN, and the laboratory personnel. Other users of this guide may include IDSR focal persons at all levels, training officers, curriculum developers, and Ministries of Health and their partners. The laboratory focal person or chief medical officer can use this guide to develop a plan to establish or strengthen a NPHLN. This guideline can be used to advocate for political commitment and funding at national levels in support of

http://www.afro.who.int/en/divisions-aprogrammes/dsd/health-technologiesa-laboratories.html

Guide for National Public Health Laboratory Networking To Strengthen Integrated Disease Surveillance and Response (IDSR) (WHO/CDC)


Case study page no.

http://whqlibdoc.who.int/publications/2 009/9789241597906_eng.pdf

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Page 66 of 117


Guide to Implementation of the WHO Multimodal Hand Hygiene Improvement Strategy (WHO)

Hand Hygiene in Outpatient and Home Based Care and Long-Term Care Facilities

Infection Prevention and Control Minimum Standards (RCN and IPS)

Infection Prevention Guidelines for Facilities with Limited Resources JHPIEGO

Purpose

 To facilitate local implementation and evaluation of a strategy to improve hand hygiene at individual health care facilities  To assist health care facilities in preparing a comprehensive action plan to improve hand hygiene  To support the components of the WHO multimodal hand hygiene improvement strategy A Guide to the Application of the WHO Multimodal Hand Hygiene Improvement Strategy and the “My Five Moments for Hand Hygiene” Approach beyond the acute hospital setting These ten standards are the minimum standards that the Royal College of Nursing and the Infection Prevention Society believe should be accepted and mandated by Governments, the relevant UK Departments of Health and, where applicable, all independent health or social care organisations. Rationales have been included in order to highlight current issues relevant to the standards.

The manual features infection prevention guidelines for outpatient settings as well as hospitals providing general medical, surgical, and


laboratory strengthening to improve detection, confirmation, response, and prevention of priority infectious diseases. The guideline is also useful for laboratory personnel so they know and comply with its objectives and content.  Can be used in a variety of health care facilities to improve hand hygiene, regardless of their starting point  Can apply to any setting in which health care is delivered

A comprehensive guide that takes account of the challenges of implementing and measuring hand hygiene improvement in a diverse range of settings where health care delivery might occur The ten standards cover hand decontamination, cleaning, competence and training. Hand hygiene forms the first of the standards, emphasising that all nurses should have access to effective, accessible and well-tolerated hand decontaminants at the point of care/treatment to facilitate optimal hand hygiene compliance in accordance with the 5 moments for hand hygiene. JHPIEGO is a not for profit healthcare organization affiliated with Johns Hopkins University. JHPIEGO works with over 40 governments across the


Where to find

Case study page no.

http://www.who.int/gpsc/5may/Guide_t o_Implementation.pdf

http://www.who.int/gpsc/5may/hh_gui de.pdf

To access the general RCN infection prevention page: http://www.rcn.org.uk/development/pr actice/infection_control To access this resource: http://www.rcn.org.uk/downloads/publi cations/public_pub/002725.pdf

JHPIEGO website: http://www.jhpiego.org/ Online version of the Guidelines available at:

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Page 67 of 117


Purpose


Where to find

obstetric services. To facilitate the manual's adaptation and use, each chapter has a set of learning objectives and is fully referenced. The manual is divided into four parts: Fundamentals of Infection Prevention; Processing Instruments, Gloves, and Other Items; Implementing Infection Prevention in Healthcare Facilities; and Nosocomial Infections. (2003) Available in English.

world and has programmes in a number of African countries. Their focus is development and implementation of infection prevention and control interventions. JHPIEGO partner with Save the Children and other organizations internationally. While the main focus of JHPIEGO is on interventions to address health issues amongst women and children, particularly the reduction of maternal and neonatal mortality, the guidelines offer a useful training resource in infection control.

http://www.reproline.jhu.edu/english/4 morerh/4ip/IP_manual/ipmanual.htm

Multimodal Hand Hygiene Improvement Strategy Template Action Plan (WHO)

A guide to help you create an Action Plan specific for your health-care facility.

Multimodal Hand Hygiene Improvement Strategy and associated tools (WHO)

See tools listed below

Multimodal Hand Hygiene Improvement Strategy Tools for Evaluation and Feedback (WHO)

 To improve hand hygiene compliance  To improve infrastructure for infection control & hand hygiene  To improve healthcare worker perception and knowledge of hand hygiene The data entry analysis tools, instructions and data summary report framework are all inherently linked to the evaluation tools presented here as they provide helpful support in generating and presenting results electronically. These can therefore be used all together or the evaluation tools can be used alone, with data analysis and presentation managed at the local level. A PowerPoint presentation template



Data Entry Analysis Tool



Data Summary Report

Case study page no.

http://www.who.int/gpsc/5may/tools/sy stem_change/en/index.html

See tools listed below

http://www.who.int/gpsc/5may/tools/en /index.html

For access to the full suite of evaluation tools: http://www.who.int/gpsc/5may/tools/ev aluation_feedback/en/index.html


Can be used to feedback data to key


For access to the full suite of

Page 68 of 117
















Purpose


Where to find

Framework

into which local data can be inserted.

decision makers.

Hand Hygiene Knowledge Questionnaire for Healthcare Workers

 To assess knowledge among healthcare workers of the essential aspects of germ transmission and hand hygiene during health care

 Can be used for baseline assessment, during an intervention/training, and for follow-up

evaluation tools: http://www.who.int/gpsc/5may/tools/ev aluation_feedback/en/index.html For access to the full suite of evaluation tools: http://www.who.int/gpsc/5may/tools/ev aluation_feedback/en/index.html

Hand Hygiene Technical Reference Manual

 Introduces the importance of healthcare associated infections  Explains the 5 moments for hand hygiene  Describes correct procedures for handrubbing & handwashing General instructions on how to input data.

 Allows trainers to identify the key messages to be transmitted during educational sessions

 Observation form used to collect data on hand hygiene performance while observing healthcare workers during routine care  The compliance calculation form is designed to help staff calculate hand hygiene compliance rates based on data collected in the observation form  Tools should be used to assess baseline hand hygiene compliance To assess healthcare workers' perceptions about the impact of health-care associated infections and the importance of hand hygiene To assess senior executive managers' perceptions about the impact of health-care associated infections and the importance of hand hygiene  To evaluate the tolerability and acceptability of a single alcoholbased handrub product  To subjectively evaluate hand hygiene practices, the product itself and skin condition following use

 Tools may also be used during follow-up evaluations of hand hygiene compliance

Instructions for Data Entry and Analysis

Observation Tools: Observation Form and Compliance Calculation Form

Perception Survey for Healthcare Workers

Perception Survey for Senior Managers

Protocol for Evaluation and Comparison of Tolerability and Acceptability of Different Alcohol-based

Available in baseline and follow-up versions

Can assist in positively influencing key decision makers.

Can be used to test a new product, or after introduction of a new product


Case study page no.


For access to the full suite of evaluation tools: http://www.who.int/gpsc/5may/tools/ev aluation_feedback/en/index.html For access to the full suite of evaluation tools: http://www.who.int/gpsc/5may/tools/ev aluation_feedback/en/index.html

For access to the full suite of evaluation tools: http://www.who.int/gpsc/5may/tools/ev aluation_feedback/en/index.html For access to the full suite of evaluation tools: http://www.who.int/gpsc/5may/tools/ev aluation_feedback/en/index.html For access to the full suite of evaluation tools: http://www.who.int/gpsc/5may/tools/ev aluation_feedback/en/index.html

Page 69 of 117

Action Area 5: Health care-associated Infections Handrubs: Method 2







Protocol for Evaluation of Tolerability and Acceptability of Alcoholbased Handrub in Use or Planned to be Introduced: Method 1

Soap/Handrub Consumption Survey


Multimodal Hand Hygiene Improvement Strategy Tools for Institutional Safety Climate (WHO):





Guidance on Engaging Patients and Patient Organizations in Hand Hygiene Initiatives

SAVE LIVES: Clean Your Hands (SLCYH) Promotional DVD

Purpose

 To provide a scale for the objective evaluation of skin condition following use  To compare the tolerability of different alcohol-based handrubs  To subjectively evaluate hand hygiene practices, the product itself and skin condition following use  To provide a scale for the objective evaluation of skin condition following use  To capture the usage of various products intended for hand hygiene purposes  To understand the baseline usage of hand hygiene products  To collect data about existing infrastructures and resources for hand hygiene  To create the environment and perceptions that facilitate awarenessraising about patient safety & hand hygiene  Promotes active participation at institutional and individual levels  Achieve partnership with patients and patient organizations  Provides guidance on empowering patients, engaging with patient organizations and developing a programme to educate patients and inspire patient advocacy for hand hygiene improvement  A short film to promote hand hygiene and the SLCYH initiative  To inspire and motivate healthcare workers and patients to participate in hand hygiene improvement initiatives


Where to find



 Allows demonstration of the process of changing demand for hand hygiene products with implementation of hand hygiene improvement  Allows purchasing or production departments to foresee the amount of handrub needed Allows for baseline measurements, as well as follow-up measurement of system changes following implementation Can be used to improve patient awareness and understanding of hand hygiene


Promotes patient-provider partnerships

http://www.who.int/gpsc/5may/tools/sa fety_climate/en/index.html

Can be used at meetings, educational sessions, and public areas where patient empowerment is promoted



Case study page no.

For access to the full suite of evaluation tools: http://www.who.int/gpsc/5may/tools/ev aluation_feedback/en/index.html http://www.who.int/gpsc/5may/tools/sa fety_climate/en/index.html

Page 70 of 117


Purpose



 Provides guidance for health care facilities interested in enhancing existing hand hygiene improvement strategies  To help facilities maintain momentum and continue to improve hand hygiene  To provide a template letter for use and adaptation by a local hand hygiene co-ordinator to aid initial dialogue with key decision makers concerning investment in hand hygiene improvement  To provide a template letter for use and adaptation by a local handhygiene coordinator to convey clear messages concerning hand hygiene improvement initiatives  To aid the hand hygiene coordinator in communicating where action is required and by whom  To prompt and remind health care workers about the importance of hand hygiene and about the appropriate indications and procedures for performing it  To summarize the key messages related to when and how hand hygiene should be performed  To assist healthcare workers in complying with the 5 moments for hand hygiene approach, and knowing correct procedures for handrubbing and handwashing To explain the correct procedures for handrubbing & handwashing that are designed to remind healthcare workers to perform hand hygiene To explain the correct procedures for handrubbing & handwashing that are designed to remind healthcare





Sustaining Improvement - Additional Activities for Consideration by HealthCare Facilities

Template Letter to Advocate Hand Hygiene to Managers

Template Letter to Communicate Hand Hygiene Initiatives to Managers

Multimodal Hand Hygiene Improvement Strategy Tools for Reminders in the Workplace (WHO):







Hand Hygiene: When and How Leaflet

How to Handrub Poster

How to Hand wash Poster


Where to find

Case study page no.


 Provides a tool to engage senior managers in hand hygiene improvement initiatives  Letter can be modified to insert local information and reflect local style


 Letter can be modified to insert local information and reflect local style


 Can be adapted to reflect local context

http://www.who.int/gpsc/5may/tools/w orkplace_reminders/en/index.html

Can be distributed during training sessions for healthcare workers to keep as a personal tool & reference

Can be displayed at points of care


Can be displayed at points of care



Page 71 of 117

Action Area 5: Health care-associated Infections 



SAVE LIVES: Clean Your Hands Screensaver

Your 5 Moments for Hand Hygiene Poster

Multimodal Hand Hygiene Improvement Strategy Tools for System Change (WHO)  Alcohol-based Handrub Planning and Costing Tool







Guide to Local Production: WHOrecommended Handrub Formulations

Protocol for Evaluation and Comparison of Tolerability and Acceptability of Different Alcohol-based Handrubs: Method 2

Protocol for Evaluation of Tolerability and Acceptability of Alcoholbased Handrub in Use or Planned to be Introduced: Method 1

Purpose

workers to perform hand hygiene A screensaver for computer screens to remind healthcare workers to perform hand hygiene at the appropriate moments To provide a visual description of the 5 moments to perform hand hygiene during health-care delivery To ensure that the health-care facility has the necessary infrastructure in place to allow healthcare workers to perform hand hygiene  To help managerial staff to provide alcohol-based handrub at the point of care  To decide on whether to purchase alcohol-based handrub from an established manufacturer, or to produce it locally according to WHO guidelines  To provide a practical guide for use at the pharmacy bench during the preparation of WHO-recommended alcohol-based handrub formulations  To evaluate the tolerability and acceptability of a single alcoholbased handrub product  To subjectively evaluate hand hygiene practices, the product itself and skin condition following use  To provide a scale for the objective evaluation of skin condition following use  To compare the tolerability of different alcohol-based handrubs  To subjectively evaluate hand hygiene practices, the product itself and skin condition following use  To provide a scale for the objective


Where to find

Requires computer access


Can be displayed at point of care


Essential to have support and commitment from key senior managers


Helps to ascertain the feasibility of implementing alcohol-based handrub Requires that information be gathered regarding all local producers of alcohol-based handrub and on regional & international distributors prior to use of tool


Provides the option of local production of alcohol-based handrub in healthcare facilities that are unable to purchase it Should be used by a qualified pharmacist Can be used to test a new product, or after introduction of a new product





Case study page no.


Page 72 of 117






Soap/Handrub Consumption Survey

evaluation of skin condition following use  To capture the usage of various products intended for hand hygiene purposes  To understand the baseline usage of hand hygiene products


 To collect data about existing infrastructures and resources for hand hygiene

Multimodal Hand Hygiene Improvement Strategy Tools for Training/Education (WHO)









Purpose

Frequently Asked Questions

 To train and educate healthcare workers on the importance of hand hygiene and the "5 Moments for Hand Hygiene" approach, and the correct procedures for handrubbing and handwashing To provide answers to commonly asked questions about hand hygiene

Glove Use Information Leaflet

To explain the appropriate use of gloves with respect to the 5 Moments for Hand Hygiene approach

Hand Hygiene Technical Reference Manual

 To introduce the importance of health-care associated infections and the dynamics of cross-transmission  To explain the "My 5 Moments for Hand Hygiene" concept and the correct procedures for handrubbing & handwashing  To explain the WHO observation method To display a series of scenarios which help to convey the "My 5 Moments for

Hand Hygiene Training


Where to find

 Allows demonstration of the process of changing demand for hand hygiene products with implementation of hand hygiene improvement  Allows purchasing or production departments to foresee the amount of handrub needed Allows for baseline measurements, as well as follow-up measurement of system changes following implementation Enables delivery of clear messages with a standardized approach, not open to personal interpretation


 Provides information to healthcare workers who have questions regarding the background of WHO Patient Safety in hand hygiene initiatives  Can be utilized in initial training or when questions arise  May be used during training sessions  Healthcare workers may keep as a reference Assists trainers with identifying the key messages to be transmitted during educational sessions

http://www.who.int/gpsc/5may/tools/tr aining_education/en/index.html

Useful during training sessions



Case study page no.





Page 73 of 117

Action Area 5: Health care-associated Infections Films



 







Hand Hygiene Why, How and When Brochure

Key Scientific Publications Observation Form

Slides Accompanying the Hand Hygiene Training Films

Slides for Education Sessions for Trainers, Observers and Healthcare Workers

Slides for the Hand Hygiene Co-ordinator

Purpose

Hand Hygiene approach and the appropriate technique for handrubbing and handwashing To provide healthcare workers with a reference for the key educational messages related to why, how and when for hand hygiene To direct interested parties to noteworthy data and commentaries regarding hand hygiene  Observation form used to collect data on hand hygiene performance while observing healthcare workers during routine care  Should be used to assess baseline hand hygiene compliance To display a series of scenarios which help to convey the "My 5 Moments for Hand Hygiene approach and the appropriate technique for handrubbing and handwashing  To train the trainers in order to make them aware of the essential learning objectives and key messages to be transmitted to healthcare workers regarding hand hygiene improvement  To train the observers responsible for monitoring hand hygiene compliance to understand the basic principles of hand hygiene and the methods of hand hygiene observation  To provide comprehensive training for all healthcare workers  To assist hand hygiene leads in explaining the need for hand hygiene to senior managers and other key players  To assist hand hygiene leads in advocating standards of hand


Where to find

Can be used during training and as a reference for health-care providers


Useful for those who would like additional information on certain topics May also be used during follow-up evaluations of hand hygiene compliance


Useful during training sessions Requires access to computer/audiovisual equipment (Power Point slides)


Requires access to computer/audiovisual equipment (Power Point slides)


Requires access to computer/audiovisual equipment (Power Point slides)



Case study page no.


Page 74 of 117






Sustaining Improvement - Additional Activities for Consideration by HealthCare Facilities

Your 5 Moments for Hand Hygiene Poster

National Electronic Library of Infection, UK

NHS Evidence - Infections

NRIC (National resource for Infection Control, UK)

Purpose

hygiene, explaining the importance of the "My 5 moments for Hand Hygiene" approach, and outlining the facility's action plan to improve hand hygiene  Provides guidance for health care facilities interested in enhancing existing hand hygiene improvement strategies  To help facilities maintain momentum and continue to improve hand hygiene To provide a visual description of the 5 moments to perform hand hygiene during health-care delivery NeLI is a digital library bringing together the best available on-line evidence-based, quality-tagged resources on the investigation, treatment, prevention and control of infectious disease. The infections specialist collection aims to keep health professionals up to date by providing convenient and comprehensive access to the best available evidence on the diagnosis, prevention, treatment and control of infectious diseases. NHS Evidence – Infections is part of the National Institute for Clinical Excellence NHS Evidence and provides free access to clinical and non-clinical information local, regional, national and international. Information includes evidence, guidance and Government policy.

NRIC is a project developed by healthcare professionals, aimed at being a single-access point to existing


Where to find

Case study page no.


Can be displayed at point of care


This is connected to the National Resource for Infection Control – a potentially useful portal for accessing a range of infection prevention resources.

Access the library: http://www.neli.org.uk/IntegratedCRD. nsf/NeLI_Home1?OpenForm

Access the main site: http://www.evidence.nhs.uk/search?q =healthcare%20associated%20infecti on

The electronic resource enables the user to access resources related to infection control in a number of ways


To access NRIC: http://www.nric.org.uk/IntegratedCRD. nsf/NRIC_Home1?OpenForm

Page 75 of 117


Natural Ventilation for Infection Control in Healthcare Settings (WHO)

Purpose


resources within infection control for both Infection Control and all other healthcare staff. NRIC is supported by the UK Department of Health and City University, London.

– searches can be undertaken alphabetically, by health care setting speciality, by clinical practice category, by route of transmission, by disease/organism and by policy/guidance. Users are presented with the title of the resource, the type of resource, the level of evidence associated with the resource, its source and publication date. Each resource is reviewed providing the user with comprehensive information on its utility. This document is the result of over 2 years of work with multidisciplinary input including engineers, architects, infection control experts and microbiologists. The final document offers a design and operation guide for hospital planners, engineers, architects and infectioncontrol personnel. The recommendations in this WHO guideline followed a systematic review of the literature on the association of ventilation and disease transmission, as well as effective natural ventilation solutions for infection control.

In this new (2010) guideline, natural ventilation is considered for the first time among the effective measures to control infections in health care. Such a recommendation from WHO demonstrates a growing recognition of the role of ventilation and natural ventilation for infection control.


Where to find

Case study page no.

http://www.who.int/water_sanitation_h ealth/publications/natural_ventilation/e n/

Page 76 of 117


Purpose


Where to find

Sterilization Manual for Health Centers (PAHO)

Published by the Pan American Health Organization (PAHO) in 2009 with support from USAID, this 175 page manual is an updated version of the sterilization manual, published by PAHO Headquarters to inform health workers about the simple protocols and procedures that have been developed to prevent hospitalacquired infections both inside and outside the sterilization plant. The guidelines included in this manual show the steps to follow in cleaning, preparing, sterilizing, storing and transporting hospital equipment so as to obtain sterile material. The manual aims to increase awareness of sterilization in order to maximise patient safety. The members of the Eli Lilly MDR-TB Partnership most directly concerned with this issue have initiated this joint workshop focusing on health care worker safety in the context of drugresistant TB in low and middle income countries, bringing together South African hospital managers, nurses, microbiologists and physicians working in the context of drugresistant TB (DR-TB), to jointly examine and address the issues

The manual provides a thorough overview of the main methods used for disinfection and sterilization, and has been described as a user friendly and practical guide for healthcare workers, particularly in limited resource settings.

Access the PAHO website at: http://new.paho.org/

The identification of Extensive drugresistant tuberculosis, the increase in Multidrug-resistant tuberculosis (MDR-TB) in the context of the Human Immunodeficiency Virus (HIV) pandemic, and the high media attention to both issues has, among other things, focused attention and concern on the control of infection and general safety in the health care workplace. Addressing health worker safety is an issue that must be addressed, by health systems and health workers.

http://www.icn.ch/projects/tb-in-theworkplace/

TB in the workplace (ICN) Health care worker safety in the context of drug resistant TB in low and middle income countries


Case study page no.

Access the manual at: http://new.paho.org/hq/index.php?opti on=com_content&task=view&id=2106 &Itemid=229&lang=en

http://www.icn.ch/images/stories/docu ments/projects/tb/DURBANSeminar_report__from_Uta_Grosse.p df

Page 77 of 117


Purpose


Where to find

Updated National Evidencebased Guidelines for Preventing Health-Care Associated Infection in NHS Hospitals in England 2007 (EPIC 2)

These updated national guidelines (epic2), commissioned by the Department of Health (England), provide comprehensive recommendations for preventing HCAI in hospitals and other acute care settings based on the best currently available evidence. Each section of the recommendations is accompanied by key audit criteria to aid in monitoring implementations. 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

The guidelines can be appropriately adapted and used by all hospital practitioners.

Access the EPIC 2 website of Thames Valley University, UK: http://microtrainees.bham.ac.uk/lib/ex e/fetch.php?media=epic2_20_2021aug06_20final_20draft_20for_2 0consultation.pdf

The training focuses on prevention of surgical site infections, central lineassociated bloodstream infections, ventilator-associated pneumonia, catheter-associated urinary tract infections, Clostridium difficile and methicillin-resistant Staphylococcus aureus (MRSA). In addition, it includes information on basic protocols for universal precautions and isolation precautions to protect patients, visitors, and practitioners from the most common disease transmissions. The training promotes these key behaviors: Teamwork; Communication; Hand washing; Vaccination against the flu; Appropriate use of antibiotics; and Proper insertion, maintenance, and removal of devices, such as catheters and ventilators.

http://www.hhs.gov/ash/initiatives/hai/t raining/

U.S. Department of Health & Human Services- Partnering to Heal: Teaming up against Healthcare-Associated infections


Case study page no.

Page 78 of 117


Purpose


Where to find

WHO Policy on TB infection control in Health-care facilities, congregate settings and households

WHO developed this policy in response to demand from countries for guidance on what to do and how prioritize TB infection control measures at the national level.

The document focuses on providing guidance on TB infection control in health-care facilities, because people working in such settings have a higher incidence of TB than the general population. In addition household contacts of TB patients also exceeds the incidence found in the general population, therefore, the document also provides guidance on preventing TB transmission in congregate settings and households. (WHO, 2009) Central venous catheters are lifesaving and the majority of patients in intensive care units (ICUs) have them placed in order to receive medicine and fluids. However, the use of these can result in serious bloodstream infections. Bloodstream infections associated with the insertion and maintenance of central venous catheters (CVC) are among the most dangerous complications that can occur. These complications worsen patients’ health, prolong hospital stay and increase the cost of care The nine solutions are based on interventions and actions that have addressed patient safety problems in some countries. They are now being made available in an accessible form for use and adaptation by WHO Member States to re-design patient care processes and to make them safer.

http://www.who.int/tb/publications/200 9/infection_control/en/index.html

Preventing Bloodstream infections from central line venous catheters (WHO)

This document addresses the issue of Catheter-related bloodstream infection (CRBSI) which is the most common cause of health care-associated infection to the bloodstream

WHO Patient Safety Solutions

Nine patient safety solutions to reduce the toll of health care-related harm affecting millions of patients daily, worldwide, were launched on 2 May 2007, by the World Health Organization (WHO)


Case study page no.

Main document can be found at: http://whqlibdoc.who.int/publications/2 009/9789241598323_eng.pdf French version: http://whqlibdoc.who.int/publications/2 010/9789242598322_fre.pdf

http://www.who.int/patientsafety/imple mentation/bsi/en/index.html

http://www.who.int/patientsafety/event s/07/02_05_2007/en/index.html Single Use of Injection Devices http://www.who.int/patientsafety/soluti ons/patientsafety/PS-Solution8LowRes.pdf Improved Hand Hygiene to Prevent Health Care-Associated Infections http://www.who.int/patientsafety/soluti ons/patientsafety/PS-Solution9.pdf

Page 79 of 117

Action Area 6: Healthcare Worker Protection Action Area 6: Healthcare worker Protection

Purpose


Where to find

A Practical Guide on the Prevention of Nosocomial nd Infections (2 edition) 2008 (WHO)

Developed by WHO’s Global Alert and Response unit these guidelines provide a comprehensive introduction to infection prevention and control. The information is intended to assist administrators, infection control personnel, and patient care workers in facilities with limited resources in the initial development of a nosocomial infection control programme, including specific components of such programmes. The manual includes a chapter on preventing infections in staff.

This manual has been developed to be a practical, basic, resource which may be used by individuals with an interest in nosocomial infections and their control, as well as those who work in nosocomial infection control in health care facilities. It is applicable to all facilities, but attempts to provide rational and attainable recommendations for facilities with relatively limited resources. Additional reading in specific areas is provided in the list of WHO relevant documents and infection control texts at the end of the manual.

English version of the Guide: http://www.who.int/csr/resources/public ations/whocdscsreph200212.pdf

First Do No Harm: Introducing Autoclavable Syringes and ensuring injection safety in immunization systems of developing countries (WHO) Guidance Note on healthcare worker safety from HIV and other blood borne infections, Human Development Network (World bank)

Guidelines for Prevention of TB in resource limited settings (WHO)

A step by step guide to introducing autoclavable syringes with an emphasis on developing countries. Presents an assessment framework and checklist for injection safety and cost calculation tools.

Case study page no.

French version of the Guide: http://www.who.int/csr/resources/public ations/WHO_CDS_CSR_EPH_2002.1 2fr.pdf

Access the document: http://www.who.int/vaccinesdocuments/DocsPDF02/www704.pdf

This document produced by the World Bank's Human Development Network describes guidance for protection from occupational exposure to blood borne infections with a specific focus on resources poor settings by a combination of low cost technologies and proper education and training methods.

Illustrates a holistic approach to HCW protection. Key concepts are explored for use at the institutional level. Guidance is also provided on National strategy formulation.

These guidelines published in 1999, provide discussion and recommendations for the district and referral level (thus accounting for the

WHO state that these guidelines provide cost effective interventions that can be directly implemented (or modified) within a facility at the district

http://siteresources.worldbank.org/HE ALTHNUTRITIONANDPOPULATION/ Resources/2816271095698140167/GoldGuidanceNote.p df

In many sections the document mentions "international best practice" as well as "what can be achieved with limited resources".


Access the guidelines: http://www.who.int/tb/publications/who _tb_99_269.pdf

Page 80 of 117

Action Area 6: Healthcare worker Protection

Guidelines on Health services and HIV/AIDS, 2005 (Joint ILO/WHO)

Guidelines on post Exposure prophylaxis (PEP) to prevent HIV Infection, 2007 (Joint WHO/ILO)

Health Protection Agency HIV and AIDS: information

Purpose


wide variety of health care facilities) based upon three levels of infection control: administrative, environmental, and personal respiratory protection.

or referral level in any resource-limited setting. Efforts should be made to execute such control strategies to prevent nosocomial transmission of M. tuberculosis. Such measures serve not only to conserve resources in terms of direct costs due to treatment of healthcare workers and indirect costs in terms of loss of healthcare workers specialising in the management of TB patients, but also in reducing the burden due to tuberculosis. A collection of 12 fact sheets allow the user to get practical information about technical aspects of occupational safety.

This is a set of guidelines developed by WHO and ILO that primarily targets governments, public and private employers, scientific and academic institutions and all health care institutions for sound management of HIV/AIDS at work place and prevention of occupational exposure. They are based on ten key principles of ILO code of practice on HIV/AIDS in the work place and can be applied to deal with occupational safety issues such as legal and policy framework, safe work place practices and exposure incident management. Guidelines by WHO/ILO that focuses specifically on methods for post exposure prophylaxis to prevent HIV/AIDS by providing a framework to aid PEP policy development as well as service implementation. The guidelines focus on occupational exposure and exposure through sexual assault. A specific chapter deals with occupational exposure.

Where to find

Case study page no.

http://www.who.int/hiv/pub/prev_care/ who_ilo_guidelines.pdf

A comprehensive document which covers various aspects of sound management of occupational exposure to HIV/AIDS and can be utilized by a wide range of audience.

Beneficial with patient safety perspective as healthcare workers face accidental exposure to needle stick injuries and blood/body fluids in their routine clinical services.

http://whqlibdoc.who.int/publications/2 007/9789241596374_eng.pdf

Collection of annexes provide useful information including: PEP regimens, patient checklist for PEP; Indicators for PEP evaluation; patient information sheets; side effect counselling etc.

A provision of resources/guidance for health care workers in prevention of HIV and other blood borne infections


http://www.hpa.org.uk/web/HPAweb& HPAwebStandard/HPAweb_C/119573 3818951

Page 81 of 117


Purpose


Where to find

Case study page no.

A collection of WHO tools focused on preventing needle stick injuries in healthcare workers. This includes general information, guidelines, fact sheets and best practices on prevention of needle stick injuries. There is also information on injection safety, training materials, surveillance, etc. The toolkit also contains resources from other sources such as International Council of Nursing, American Nurses Association and US CDC. Tool for the Assessment of Injection Safety and the Safety of Phlebotomy, Lancet Procedures, Intravenous Injections and Infusions

Wide range of resources on different aspects of HCW protection, easily available and usable by health professionals (clinicians and nurses)

http://www.who.int/occupational_health /activities/pnitoolkit/en/index.html

Tool C for the assessment of the safety of injections was first implemented in 2000, and has been used in over 90 national injection safety assessments since then. Although the main purpose for this assessment tool is to assess procedure safety at a national level, it also may be used at other levels. If a country is large and has many health facilities, assessments can be performed at a sub-national level (province or state) without changes in the sampling strategy. An abbreviated version of the questionnaire that is included can be used for supervision of practices at a district level or within a facility, or even for self-assessment by providers.

http://www.who.int/injection_safety/Inje ction_safety_final-web.pdf

and guidance in the occupational setting Protecting Healthcare workers: Preventing Needle stick injuries Toolkit (WHO)

Revised Injection Safety Assessment Tool (2008) (WHO)

Safe Injection Global Network (SIGN) Alliance range of resources (WHO)

The "Safe Injection Global Network" (SIGN) has been established as a voluntary coalition of stakeholders aiming to achieve safe and appropriate use of injections throughout the world. SIGN has developed a range of resources to assist in this aim


Access the main SIGN site: http://www.who.int/injection_safety/sig n/en/ Access information on the weekly electronic newsletter: http://www.who.int/injection_safety/ne wsletter/SIGNPost/en/index.html

Page 82 of 117


Purpose


including a weekly electronic newsletter and Guiding Principles to Ensure Injection Device Security. A toolbox of resources is available including: Policy Management Tools; Technical Tools and resources.


Published by the Pan American Health Organization (PAHO) in 2009 with support from USAID, this 175 page manual is an updated version of the sterilization manual, published by PAHO Headquarters to inform health workers about the simple protocols and procedures that have been developed to prevent hospital-acquired infections both inside and outside the sterilization plant. The guidelines included in this manual show the steps to follow in cleaning, preparing, and sterilizing, storing and transporting hospital equipment so as to obtain sterile material.

The manual provides a thorough overview of the main methods used for disinfection and sterilization, and has been described as a user friendly and practical guide for healthcare workers, particularly in limited resource settings. The manual aims to increase awareness of sterilization in order to maximise patient safety.


Where to find

Case study page no.

Access the Guiding Principles (English): http://www.who.int/injection_safety/WH OGuidPrinciplesInjEquipFinal.pdf Access the Guiding Principles (French): http://www.who.int/injection_safety/Gui ding_Principals_FR.pdf Access the toolbox: http://www.who.int/injection_safety/tool box/en/ Access the PAHO website at: http://new.paho.org/ Access the manual at: http://new.paho.org/hq/index.php?optio n=com_content&task=view&id=2106&I temid=229&lang=en

Page 83 of 117

Action Area 7: Healthcare Waste Management Action Area 7: Healthcare Waste Management

Purpose


Where to find

Assessment of Small Scale Incinerators for Healthcare Waste, WHO, 2004

This document by WHO provides an overview of the environmental aspect of hazards of HCW by focusing on small scale incinerators that form a major part of HCWM in developing countries (particularly for sharp waste) and gives the best practises for incinerator use which include proper design, construction, operation, maintenance, training and management, regulations and emission standards for incinerators so as to prevent emissions of toxic gases. This comprehensive document by WHO EMRO and Center for Environmental Health, describes HCWM in six key steps that can be followed at the health care establishment level. These steps include designating a responsible person for HCWM, conducting a HCWM survey and inviting suggestions, recommending improvements and implement them, prepare a plan for HCWM, approve and start implementation and finally revise it at regular intervals. This WHO tool is designed to help the user estimate costs related to health care waste management at the health care facility (HCF), central treatment facility or cluster, and national levels. The tool format is an excel spreadsheet ready for use in feeding into national policy development. The primary audience for the tool is senior management personnel responsible for design, implementation, evaluation & updating of national policy and plans for health care waste management

It can be an important resource for use in low resource countries where majority of the environmental health hazards are attributed to improper functioning of incinerators.

http://www.who.int/immunization_safety/public ations/waste_management/en/assessment_S SIs.pdf

Six simple steps to manage HCW can be easily understood and followed by Health care institutions at any level.

http://www.emro.who.int/informationresources/publications/

The spreadsheet has been prepared with the aim of creating a simple, useable tool that fits as closely as possible to field reality. Separate versions available for low, middle and high income countries.

http://www.healthcarewaste.org/en/documents. html?id=218

This WHO guidance document provides assistance to countries in assessing the existing national situation in healthcare waste management and to develop a National Action

The audience is national policy makers. The document has a specific focus on developing countries and takes into consideration factors such

Complete document can be accessed on http://www.who.int/water_sanitation_health/me dicalwaste/en/napguidance.pdf

Basic steps in the preparation of healthcare waste management plan for Health Care Establishments, WHO EMRO and CEHA, 2002

Costing Analysis Tool for Healthcare waste Management

Guidance for the Development and implementation of a National Action Plan, 2004


Case study page no.

Page 84 of 117


Purpose


(WHO)

Plan (NAP). The document outlines five areas within a NAP: general framework; assessment and option development; legal considerations; financial considerations; and awareness campaigning. The document aims to provide a way of setting priority action areas in HCWM e.g. sharps disposal, expired dugs. Guidelines on How to Construct, Use, and Maintain a Waste Disposal Unit

as social, economic context, national public health budget and overall health system. It also stresses sustainability of the action plan. The document does not however provide details on monitoring and evaluation A very practical overview of interest to anyone wanting to learn more about operational aspects of waste management based on and informed by field trials in Burkhina Faso, Kenya and Senegal.

Managing Healthcare Waste Disposal

Management of solid healthcare waste at Primary Care Centers: A decision Making guide (WHO)

Management of waste from injection activities at district level- Guidelines for District health Managers

National Healthcare Waste Management Plan, 2009 (Angola)

The objective of this document is to provide guidance for selecting the most appropriate strategies for safely managing solid waste generated at Primary Health-Care centres (PHCs) in developing countries. The main tool consists of six decision-trees aimed at assisting the user in identifying appropriate waste management methods. The guide takes into consideration the most relevant local conditions, the safety of workers and of the general public as well as of environmental criteria. This guide provides a combination of plans and tools for use in managing healthcare waste resulting from injection activities at district level. The target facilities include primary and secondary health care facilities that generate healthcare waste from mass health activities such as immunization. It is divided into seven sections that provide information on assessment; waste handling options; strategy development; defining equipment needs; sustainability; health authority engagement and evaluation Prepared under the HAMSET project, this document can potentially serve as a reference point for other African countries when developing national healthcare waste management plans, through adoption of concepts presented in the

Where to find

Case study page no.

http://www.healthcarewaste.org/fileadmin/user _upload/resources/WDU_guidelines2_en.pdf

Visit the WHO Health Care Waste and its Safe Management Website: http://www.healthcarewaste.org/en/115_overvi ew.html Access the full document: http://www.who.int/water_sanitation_health/me dicalwaste/hcwdmguide/en/ Link Refreshed 10/12/2011 Available in French at:

http://www.who.int/water_sanitation_healt h/medicalwaste/gestiondesdechetsguide. pdf The main focus is on sharp waste which poses a hazard not only for the healthcare workers but the community like children and rag pickers (problem in developing countries). It contains various tools and tables that can be utilized e.g. assessing present situation, calculating potential budget, monitoring and evaluation and pictures. The document is focused on HCWM at the national level and provides a country level view. It covers a wide range of topics ranging from assessment of current situation to


http://www.who.int/water_sanitation_health/me dicalwaste/phe_wsh_mwi_injections_report_e n.pdf

Link for HAMSET project http://web.worldbank.org/external/projects/mai n?pagePK=104231&piPK=73230&theSitePK= 40941&menuPK=228424&Projectid=P083180, Link for Angola's Waste management Plan

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PATH Resources on Healthcare waste management

Preparation of National Healthcare Waste Management Plans in Sub-Saharan Countries (WHO)

Rapid Assessment Tool for Country level

Safe Healthcare Waste Management Policy Paper (WHO) Safe Healthcare Waste Management: for a national strategy for healthcare waste management, Aide Memoire (WHO) Starting Healthcare Waste Management in Medical institutions - A Practical

Purpose


Where to find

Angola National Plan. For example, the implementation strategy focused on five key areas provides a useful framework for action.

tools for preparing a national plan. The logical structure of the plan presented in Table 14 (section 5) may be particularly useful. PATH is familiar to the African context. Examples of action on HCWM in African countries can be accessed and learned from e.g. national plan for healthcare waste management developed by Eritrea.

http://siteresources.worldbank.org/INTANGOL A/Resources/HCWMP-Plan_09.pdf

Online collection of resources in HCWM by PATH, that works in many African countries. The website has a range of resources from various organizations, including resources on national policy and planning, district and facility level policy and planning, key technical resources on specific subjects, field evaluations, advocacy materials, training materials and links to other online resources. Published in 2005 this document provides background information and assessment and planning tools to assist healthcare waste management advisors with developing and implementing national-level plans.

Case study page no.

http://www.path.org/projects/health_care_wast e_resources.php#policy

Visit the WHO Healthcare Waste and its Safe Management Website: http://www.healthcarewaste.org/en/115_overvi ew.html Full document can be accessed on http://archive.basel.int/pub/techguid/gm_hc_su ssahara_e.pdf http://www.who.int/water_sanitation_health/me dicalwaste/ratupd05.pdf

This WHO tool is part of an overall strategy to reduce the hazards of mismanaged healthcare waste, promote best practices and help develop HCWM safety standards. The tool aims to enable the gathering of essential data in a short period of time (10-15 days) to have a sufficient understanding of the situation regarding HCWM at a national level. Outlines the guiding policy principles together with short medium and long term strategy considerations relating to the safe management of waste This Aide Memoir published in 2000 presents a 2 page summary of key policy considerations, awareness and training considerations and management options for dealing with healthcare waste.

The aim of the tool is to gather sufficient relevant information so as to provide decision makers with necessary data to help them elaborate a national action plan.

A useful supplementary leaflet for advocating for safer waste management.

Link for Aide Memoire http://www.healthcarewaste.org/documents/aid ememoire_gb.pdf

This text by WHO EURO provides a standard approach which can be followed for effective segregation, storage and transportation of

The document provides a standard and simple approach focused on sharp management. The document

http://www.bvsde.paho.org/bvsacd/cd52/0368 30/intro.pdf

Policy paper can be accessed from http://www.who.int/water_sanitation_health/me dicalwaste/en/hcwmpolicye.pdf


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Purpose


Approach (WHO)

healthcare waste within hospitals, according to the degree of hazards it poses. It aims to provide a starting point for action and outlines 15 key steps for action. The important link with a working infection control committee is highlighted, as is the involvement of senior hospital leadership. Published by the Pan American Health Organization (PAHO) in 2009 with support from USAID, this 175 page manual is an updated version of the sterilization manual, published by PAHO Headquarters to inform health workers about the simple protocols and procedures that have been developed to prevent hospitalacquired infections both inside and outside the sterilization plant. The guidelines included in this manual show the steps to follow in cleaning, preparing, sterilizing, storing and transporting hospital equipment so as to obtain sterile material.

stresses methods like staff training and refresher courses for improving HCWM. The content can be applied to an African institution taking careful note of the local context.


The manual provides a thorough overview of the main methods used for disinfection and sterilization, and has been described as a user friendly and practical guide for healthcare workers, particularly in limited resource settings.

Where to find

Case study page no.

Access the PAHO website at: http://new.paho.org/ Access the manual at: http://new.paho.org/hq/index.php?option=com _content&task=view&id=2106&Itemid=229&la ng=en

The manual aims to increase awareness of sterilization in order to maximise patient safety.


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Action Area 8: Safe Surgical Care Action Area 8: Safe Surgical Care

Purpose


Where to find

Guidelines: Surgical Site Infection (NICE)

Issued in 2008 this guideline covers adults and children who are going to have a cut through the skin for an operation. The guideline was developed by the UK National Collaborating Centre for Women’s and Children’s Health, which is linked with the Royal College of Obstetricians and Gynaecologists. The Collaborating Centre worked with a group of healthcare professionals (including consultants, GPs and nurses), patients and carers, and technical staff, who reviewed the evidence and drafted the recommendations. The recommendations were finalised after public consultation. The Guidelines form part of the WHO Safe Surgery Saves Lives programme and are central to the efforts to improve surgical safety and reduce the number of surgical deaths and complications worldwide. This toolkit was developed by the Clinical Procedure Unit in collaboration with the Global Initiative for Emergency and Essential Surgical Care (GIEESC). This is a range of resources on minimum standards in emergency, surgery, trauma, obstetrics and anaesthesia at first-referral level health care facilities.

The guideline outlines key priorities for implementation and provides implementation tools. The guideline addresses perioperative, intraoperative and post operative aspects of infection prevention.

Access background information on the guidelines: http://www.nice.org.uk/CG74 Access the full PDF of the guidelines: http://guidance.nice.org.uk/CG74/Guidance/ pdf/English

The guidelines have been extensively pilot tested across the globe.

http://www.safesurg.org/uploads/1/0/9/0/109 0835/guidelines.pdf

Guidelines for Safe Surgery (WHO)

Integrated Management for Emergency and Essential Surgical Care (IMEESC) tool kit (WHO)

Surgery and Healing in the Developing World (2005)

The target for this is policy-makers, managers, and health-care providers (surgeons, anaesthetists, non-specialist doctors, health officers, nurses, and technicians). It contains teaching guidelines on surgery, training curriculum on surgical skills (documents and videos), best and safe practices for clinical procedures and quality and safety protocols. Available as a PDF, this book by Geelhoed (a Professor of Surgery and International Medical Education/Professor of Microbiology and Tropical Medicine

Case study page no.

http://www.safesurg.org A comprehensive collection of resources targeting a wide audience and applicable for low and middle income settings. Simple guidelines that are easy to understand and use in health care facilities.

The book is intended as a resource for novice or experienced individuals or teams undertaking international work in the field of surgery within


http://www.who.int/surgery/publications/imee sc/en/index.html Available to download from the above link. Videos are available only on CDs which can be ordered from WHO, Department of Essential Health Technologies.

PDF: http://www.dhmc.org/dhmc-internetupload/file_collection/geelhoed_surgery.pdf

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Surgery in Africa – Monthly Review

Surgical Care at District Hospital (WHO)

Surgical Checklist Range (NPSA)

Surgical Safety Checklist (WHO)

Purpose


George Washington University Medical Center, Washington, D.C.) presents a collection of “how I do it” from 50 international authors.

developing countries. There is also a chapter on surgical infections by Robert Blanchard, a Canadian academic surgeon. Accredited by the Royal College of Physicians and Surgeon of Canada to award Maintenance of Competence credits for participation in the CME questionnaire included with each month’s Review. Users can access an international discussion group and Resource Library.

Surgery in Africa is a self-directed online, journalbased course for surgical trainees who are undertaking the Fellowship of the College of Surgery (FCS). The format is of monthly reviews, on topics of surgical interest, referenced with appropriate full-text books and articles adhering to the principles of evidence-based medicine. Surgery in Africa produce a monthly review and archived material is freely available on a range of relevant topics This manual is a part of the WHO IMEESC Toolkit with a special focus on surgical care at district level health care facilities where there is a shortage of technical expertise on safe surgical procedures and trained human resources which in turn contributes to high post surgical mortality rates. The Manual is divided into six parts: organizing the district hospital surgical service; fundamentals of surgical practice; abdomen surgery; emergency obstetric care; resuscitation and anaesthesia; traumatology and orthopaedics. A Primary Trauma Care Manual within the Annex provides an overview of planning and safe management of trauma cases. The NPSA surgical safety range is aligned to the WHO Safe Surgery resources and includes an Alert, video material, the checklist and supporting information.

 To reduce the rate of major surgical complications

Where to find

Case study page no.

General website: http://www.utoronto.ca/ois/SIA.htm Resource Monthly Review 2008: Surgical Site Infections (SSIs), Antimicrobial Agents, Universal Precautions and Post-exposure Prophylaxis (2008 Archives): http://www.ptolemy.ca/members/archives/20 08/Surgical%20Sites/index.html

Beneficial in African context with district level hospitals catering to the health needs of majority of population due to lack of access to tertiary health care.

http://www.who.int/surgery/publications/en/S CDH.pdf

The NPSA National Reporting and Learning Service (NRLS) in collaboration with an expert reference group, has adapted the WHO checklist for use in England and Wales. It contains the core content but can be adapted locally or for specific specialties through usual clinical governance procedures.  Simple, easy to use  Can be modified for use in specific

Access the full range of resources: http://www.nrls.npsa.nhs.uk/resources/clinic al-specialty/surgery/?entryid45=59860


This Manual is part of the WHO Blue Trunk Library that is designed for use in district health centres in Africa http://www.who.int/ghl/mobile_libraries/bluetr unk/en/index.html

http://www.who.int/patientsafety/safesurgery /en/index.html

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114


Surgical Safety Checklist Checklist Implementation Manual (WHO) Surgical Safety Checklist Frequently Asked Questions (WHO)

Surgical Safety Checklist How NOT to Use the Checklist Video (WHO)

Purpose


 To reinforce accepted safety practices and ensure that they are followed in order to minimize common, avoidable risks to surgical patients  To foster better communication and teamwork between surgeons, anesthesia professionals, nurses, technicians and other operating room personnel To provide suggestions on how to implement the Surgical Safety Checklist

settings  Low cost to implement  Can be implemented quickly (within 1 month)  Pulse oximetry required  Adequate access to antibiotics required.

 To answer general questions about the Checklist and the Safe Surgery Saves Lives initiative  To answer questions frequently asked by those interested in implementing the checklist These videos are intended to teach potential users how to and how not to perform the checklist in a real-world environment.

Surgical Safety Checklist How to Use the Checklist, Complex Case Video (WHO) Surgical Safety Checklist How to Use the Checklist Video (WHO)

These videos are intended to teach potential users how to and how not to perform the checklist in a real-world environment.

Surgical Safety Checklist Safe Surgery Brochure (WHO)

To provide an overview of the background and objectives of the Safe Surgery Saves Lives campaign

Surgical Safety Checklist Safe Surgery Checklist Modification Guidelines (WHO) Surgical Safety Checklist Speakers' Kit (WHO)

To provide a guideline for modifying the Surgical Safety Checklist to better meet the needs and processes of care in specific environments

These videos are intended to teach potential users how to and how not to perform the checklist in a real-world environment.

Power point presentation to teach colleagues about the Safe Surgery Saves Lives campaign and to ask them to consider implementing the checklist


Where to find

Case study page no.

http://www.safesurg.org

http://www.who.int/patientsafety/safesurgery /en/index.html http://www.safesurg.org http://www.who.int/patientsafety/safesurgery /en/index.html http://www.safesurg.org http://www.who.int/patientsafety/safesurgery /en/index.html http://www.safesurg.org http://www.who.int/patientsafety/safesurgery /en/index.html http://www.safesurg.org http://www.who.int/patientsafety/safesurgery /en/index.html http://www.safesurg.org http://www.who.int/patientsafety/safesurgery /en/index.html http://www.safesurg.org http://www.safesurg.org/uploads/1/0/9/0/109 0835/checklist_modification.pdf

http://www.who.int/patientsafety/safesurgery /en/index.html http://www.safesurg.org

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Purpose

Surgical Safety Checklist Starter Kit (WHO)

To help administrators, clinicians, nurses, and other patient safety personnel walk through the process of implementing the WHO Surgical Safety Checklist in a facility

Universal Protocol for Preventing Wrong site, Wrong Procedure, Wrong person Surgery: Guidance for Health Care Professionals (JC)


The Universal Protocol was created to address the continuing occurrence of wrong site, wrong procedure and wrong person surgery in Joint Commission accredited organizations in the USA. The Universal Protocol drew upon, and expanded and integrated, a series of requirements under The Joint Commission’s 2003 and 2004 National Patient Safety Goals. There are three principal components of the Universal Protocol: conducting a pre-procedure verification process, marking the procedure site, and performing a time-out before the procedure. Nine patient safety solutions to reduce the toll of health care-related harm affecting millions of patients daily, worldwide, were launched on 2 May 2007, by the World Health Organization (WHO) with a solution specifically developed around correct site surgery.


Where to find

Case study page no.

http://www.who.int/patientsafety/safesurgery /en/index.html http://www.safesurg.org

The protocol is accompanied by a range of additional resources including fact sheets and tips related to prevention.

Access this resource: http://www.anesthesiapatientsafety.com/pdfs /Wrong_Site_Poster.pdf

The nine solutions are based on interventions and actions that have addressed patient safety problems in some countries. They are now being made available in an accessible form for use and adaptation by WHO Member States to re-design patient care processes and to make them safer.

Main link : http://www.who.int/patientsafety/events/07/0 2_05_2007/en/index.html Link to -Patient safety solutions preamble- May 2007 http://www.who.int/patientsafety/solutions/pa tientsafety/Preamble.pdf Performance of Correct Procedure at Correct Body Site http://www.who.int/patientsafety/solutions/pa tientsafety/PS-Solution4.pdf


Page 91 of 117

Action Area 9: Medication safety Action Area 9: Medication Safety

Purpose


Where to find

Assuring Medication Accuracy at Transitions in Care (WHO)

WHO Patient Safety Solutions are based on interventions and actions that have addressed patient safety problems in some countries. This resource outlines the steps which health care organizations can take to ensure patient safety at patient transitions.

http://www.who.int/patientsafety/imp lementation/solutions/patientsafety/ en/index.html

Basel Statements on the future of Hospital Pharmacy

These consensus statements developed at the Global Conference on Future of Hospital Pharmacy, Basel, Switzerland reflects a preferred vision of practice in the hospital setting and provides an overarching framework for hospital pharmacy practice. The statements are divided into seven categories: overarching statements; medicines procurement; influences on prescribing; preparation and delivery of medicines; administration of medicines; monitoring of medicines; and human resources/training. WHO Patient Safety Solutions are based on interventions and actions that have addressed patient safety problems in some countries. The resource lists the strategies which should be considered by WHO Member States to ensure health-care organizations have systems and processes in place to ensure safety when dealing with concentrated electrolyte solutions.

The solution is intended to guide the redesign of care processes to prevent inevitable human errors from actually reaching patients. This resource may be of use as a reference document and is intended for use and adaptation by WHO Member States to redesign patient care processes. Health care managers and hospital workers may benefit from careful consideration of these statements. An example of a useful overarching statement focuses on the 5 Rights (right patient, right medicine, right dose, right route and right time). - Challenge: The implementation of these statements will need to be adapted depending on the type of health system in which they are used.

The solution is intended to guide the redesign of care processes to prevent inevitable human errors from actually reaching patients. This resource may be of use as a reference document and is intended for use and adaptation by WHO Member States to redesign patient care processes.

http://www.who.int/patientsafety/imp lementation/solutions/patientsafety/ en/index.html

This report prepared by the expert group on safe medication practises in 2006 for all European health organizations, focuses on medication errors and their prevention.

Benefit: It is a comprehensive resource which presents an integrated approach to improve medication safety on a wider level.

English version http://www.coe.int/t/e/social_cohesio n/socsp/Medication%20safety%20culture %20report%20E.pdf

It is divided into six sections which include

Challenge: Being specifically Europe

Control of Concentrated Electrolyte Solutions – Patient Safety Solutions (WHO)

Creation of a better medication safety culture in Europe: Building up safe medication systems


Case study page no.

English versionhttp://www.ajhp.org/cgi/reprint/66/5_ Supplement_3/s61 French versionhttp://www.fip.org/files/fip/HPS/Base l2008/translations/BaselStatements French.pdf

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Look Alike, Sound Alike Medication Names – Patient Safety Solutions (WHO)

Medicines Reconciliation, (NPSA/NICE)

Potassium Chloride, Alert 01, (NPSA)

Purpose


Where to find

prevention by learning from errors, ways to measure and evaluate medication safety, development of medicinal products' design to improve safety and contribution of medicine information practises to medication safety. An important part of the report is the Glossary on medication terms which makes it user friendly. WHO Patient Safety Solutions are based on interventions and actions that have addressed patient safety problems in some countries. Solutions are intended to act as an Aide Memoire for member states concerned with addressing risks associated with Look Alike, Sound Alike medication Names. This resource is targeted at; regulators (health authorities and agencies); pharmaceutical companies; WHO INN programme; all settings where medications are ordered, dispensed, or administered and bedside medication management situations, including selfadministration and family/caregiver administration. The National Institute for Health and Clinical Excellence (NICE) in collaboration with the National Patient Safety Agency (NPSA) have produced the guidance for the NHS on how to improve processes to ensure that any medication patients are taking prior to admission to hospital is properly documented on admission. The guidance aims to ensure that important medicines are not stopped and that new medicines are prescribed, with a complete knowledge of what a patient is already taking.

focussed, the adaptability to African context is yet to be considered.

French Version http://www.coe.int/t/E/Social_Cohesi on/socsp/Medication%20safety%20culture -Executive%20summary.pdf

The solution is intended to guide the redesign of care processes to prevent inevitable human errors from actually reaching patients. This resource may be of use as a reference document and is intended for use and adaptation by WHO Member States to redesign patient care processes.

http://www.who.int/patientsafety/sol utions/patientsafety/PSSolution1.pdf

The guidance addresses: policies, standardised systems for collecting and documenting information about current medications, involvement of pharmacists in medicines reconciliation as soon as possible after admission, the responsibilities of pharmacists and other staff in the medicines reconciliation process and strategies for working with people with communication difficulties.

Access the guidance: http://www.npsa.nhs.uk/corporate/n ews/guidance-to-improvemedicines-reconciliation/

The Alert identifies safe medication practice recommendations concerning the prescription, distribution, storage and preparation of potassium chloride solutions

The Alert can assist in helping rapid development and implementation of local policies to reduce the availability of concentrated potassium chloride

Access the Alert: http://www.nrls.npsa.nhs.uk/resourc es/?entryid45=59882


Case study page no.

114

Page 93 of 117


Resources from Global Conference on future Hospital pharmacy, 2008

Safety of medicines , A Guide to detecting and reporting Adverse Drug Reactions - Why Health

Purpose


in hospitals to reduce the risk of accidental overdose of intravenous potassium chloride concentrate solutions and other strong potassium solutions. The Alert aims to ensure that seriously ill patients in critical care units who urgently require intravenous potassium as part of their treatment can continue to receive it promptly. These are a collection of background documents that contributed to the Global Conference on Future of Hospital Pharmacy. These resources can be of potential use for countries to develop different dimensions of a hospital pharmacy model. The two over arching documents are the executive summary and the global survey on hospital pharmacy. A series of additional papers outline the current status of: pharmacist influence on prescribing of medicines; preparation and distribution of medicines; administration of medicines; monitoring of medication practice; human resources and training in hospital pharmacy.

solutions.

This WHO guide helps health care professionals in contributing to ensure medication safety by increased involvement in voluntary reporting of

This WHO guide helps health care professionals in contributing to ensure medication safety by increased involvement in voluntary reporting of

The resource can be of potential use as a basis for reflection on hospital practice in the context of current status of global practice in this field and can trace areas that require improvement with regard to medication safety.


Where to find

Case study page no.

Complete set of resources can be accessed from Am J Health-Syst Pharm—Vol 66 Mar 1, 2009 Suppl 3 Links: 1. Executive summaryhttp://www.ajhp.org/cgi/reprint/66/5_ Supplement_3/s1 2. Global survey on Hospital pharmacy http://www.ajhp.org/cgi/reprint/66/5_ Supplement_3/s13 3. Pharmacist influence on prescribing medications http://ajhp.org/cgi/reprint/66/5_Suppl ement_3/s29 4. Preparation and Distribution of Medicines http://www.ajhp.org/cgi/reprint/66/5_ Supplement_3/s35 5. Administration of Medicines http://www.ajhp.org/cgi/reprint/66/5_ Supplement_3/s42 6. Monitoring of Medication practice http://ajhp.org/cgi/reprint/66/5_Suppl ement_3/s49 7. Human resources and training in hospital pharmacy http://www.ajhp.org/cgi/reprint/66/5_ Supplement_3/s56 http://whqlibdoc.who.int/hq/2002/W HO_EDM_QSM_2002.2.pdf

Page 94 of 117


Purpose


professionals need to take action

adverse drug reactions (ADR) occurring in their clinical practice (how to recognize ADRs and how to report them) and the need to set up pharmacovigilance in countries. Nine patient safety solutions to reduce the toll of health care-related harm affecting millions of patients daily, worldwide, were launched on 2 May 2007, by the World Health Organization (WHO) with a range of solutions on medication safety.

adverse drug reactions (ADR) occurring in their clinical practice (how to recognize ADRs and how to report them) and the need to set up pharmacovigilance in countries. The nine solutions are based on interventions and actions that have addressed patient safety problems in some countries. They are now being made available in an accessible form for use and adaptation by WHO Member States to re-design patient care processes and to make them safer.



Where to find

Case study page no.

Main link : http://www.who.int/patientsafety/eve nts/07/02_05_2007/en/index.html Link to -Patient safety solutions preambleMay 2007 http://www.who.int/patientsafety/sol utions/patientsafety/Preamble.pdf -Look-Alike, Sound-Alike Medication Names http://www.who.int/patientsafety/sol utions/patientsafety/PSSolution1.pdf Control of Concentrated Electrolyte Solutions http://www.who.int/patientsafety/sol utions/patientsafety/PSSolution5.pdf Assuring Medication Accuracy at Transitions in Care http://www.who.int/patientsafety/sol utions/patientsafety/PSSolution6.pdf

Page 95 of 117

Action Area 10: Patient Safety Partnerships Action Area 10: Patient Safety Partnerships

Purpose


Where to find

An assessment of community engagement and community development approaches including the collaborative methodology and community champions

Guidance documents prepared by NICE that aims to support those working with and involving communities in decisions on health improvement that affect them. It is for people working in the NHS and other sectors who have a direct or indirect role in - and responsibility for - community engagement. It provides an overview of various approaches and recommendations which can be used to involve communities in health care improvement.

Large amount of information on community engagement mechanisms presented.

http://www.nice.org.uk/PH009

Being Open Range, UK (NPSA)

This revised guidance on communicating effectively with patients when things go wrong is a best practice guide for all healthcare staff, including boards, clinicians and patient advocates. It explains the principles behind Being open and outlines how to communicate with patients, their families and carers following harm. This guidance and the associated actions outlined in an accompanying Alert, provide reassurance that Being open is the right thing to do, and encourage NHS boards to make a public commitment to openness, honesty and transparency. The full range of tools include: Webinars for clinicians; Webinars for Board members; an Alert; Supporting Information; a Framework and an elearning module. This manual provides guidance, shares experiences and offers examples of good practice from those directly


Access the entire range at: http://www.nrls.npsa.nhs.uk/resources/ ?entryid45=65077

This manual is designed to help both UK and Developing Country Link partners to think more

The Manual is available for download via the website. It is possible to download specific relevant chapters.

International Health Links ND Manual 2 Edition (THET)

Case study page no.

Challenge: adaptability to African context.


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Measuring the Community Connections : A strategy checklist for Leaders, 2006


Patient Centred Care Improvement Guide

Purpose


Where to find

involved in Links (partnerships) between the UK and developing countries

strategically about their work.

This is a checklist developed by the American Hospital Association primarily targeting hospital leaders and health care managers in order to assess the level and efficiency of their communication with communities which allows them to cater to needs and consequently, assess and improve performance of the organization (hospitals) in delivering health care.

A means of capturing feedback on the organizations' functioning with a community perspective. Useful for APPS hospital in order to involve patients groups and communities.

(Hard copies of the Manual are available via the website to buy). To access THET home page: http://www.thet.org/ To access this resource: http://thet.org/wpcontent/uploads/2009/10/Links-ManualIn-Full-Low-Res-72dpi.pdf http://www.caringforcommunities.org/ca ringforcommunities/content/strategyche cklist.pdf

It consists of a series of checklist questions for the organization such as vision and mission, governance, leadership, quality and patient safety, financial aspect, trust and delivery of care. Ask Me 3 is a patient education program designed to promote communication between health care providers and patients in order to improve health outcomes. The program encourages patients to understand the answers to three questions: 1. What is my main problem? 2. What do I need to do? 3. Why is it important for me to do this? The series consists of a range of education resources in the form of leaflets, brochures, posters and an implementation guide The Guide contains best practices and practical implementation tools

Case study page no.

Challenge: Prepared and piloted in US, hence adaptability to African context has to be considered carefully.

Developed by the US National Patient Safety Foundation

To access general information: http://www.npsf.org/askme3/index.php

This Guide is designed as a practical resource for health care

Access this resource: http://www.ihi.org/IHI/Topics/PatientCen


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Patient Safety Champions (WHO)

Purpose


Where to find

contributed by hospitals from across the United States. The Self-Assessment Tool can help identify and prioritize opportunities for introducing patientcentered approaches. This Guide was funded by Picker Institute, an international non-profit organization that supports research in the field of patient-centered care. • Raise patient safety awareness • Form partnerships between patients, physicians, government, to collectively address patient safety issues • Opportunity for modeling of actions for patients who have experienced bad outcomes

organizations that are striving to become more patient-centered.

teredCare/PatientCenteredCareGeneral /Tools/PatientCenteredCareImproveme ntGuide.htm

• Existing network of patient safety champions can be utilized to create a broader social network • Social network is a valuable tool for education and for dissemination of information • Use Patient Safety Champions as a vehicle for improving patient safety awareness among patients, and for achieving community engagement • Promotes awareness of patient safety among patients/consumers • Use of personal stories makes patient safety issues more concrete, and may be useful in changing behaviour • Tool for achieving community engagement Participation requires attendance at Patient Safety Workshop • PS Champions may need to be from local community to be effective Useful information which can be modified for planning patient safety improvements in each of the 7 areas. The summary document can be used as a quick reference manual.

Access this resource: http://www.who.int/patientsafety/patient s_for_patient/regional_champions/en/in dex.html

Seven Steps range (NPSA)

A guide for staff who provide care in the NHS, England, and for those involved in risk management and clinical governance. The 7 Steps centre on culture, leadership, integration of risk management, promotion of reporting, patient involvement, learning and sharing and implementation.

Speak Up Initiatives for Patients (JC)

These resources form part of the Joint Commission national campaign to urge

The program features brochures, posters and buttons on a variety of


Case study page no.

NPSA general website: www.npsa.nhs.uk The 7 Steps range includes a generic resource, a summary document, a resource tailored to mental health and a resource tailored to primary care, available at http://www.nrls.npsa.nhs.uk/resources/ ?entryid45=59787&q=0%c2%acseven+ steps%c2%ac To access this resource http://www.sharp.com/choosePage 98 of 117


Stakeholder Analysis: How to do (or not to do)

Purpose


Where to find

patients to take a role in preventing health care errors by becoming active, involved and informed participants on the health care team. Heath care organizations have reported printing Speak Up materials in patient rooms; sponsoring local public service announcements; including Speak Up content in patient information materials, websites and community newsletters; distributing material at health fairs; sharing it on closed circuit patient education television; using it for staff education and orientation. Paper by Varvasovszky and Brugha in Journal of Health Policy and Planning, which illustrates a systematic approach to conducting a Stakeholder Analysis and considers various issues that can potentially be faced such as time frame, context and levels of conduction. Multiple practical steps are highlighted including: defining aims; timeframe; context and level of analysis; preparation for conducting the analysis; methods to collect, organize and analyze data; and finally presentation and use of outputs.

patient safety topics. Organizations can download and print as many copies as they would like to distribute to patients, staff and community members. The brochures include a blank panel for organizations to insert their own patient safety information, logo and contact information.

sharp/quality/speak-up-initiative.cfm

A systematic model, for identifying and engaging various individuals and organizations associated with the health services.

http://heapol.oxfordjournals.org/cgi/repri nt/15/3/338

Toolkit on Monitoring and Evaluation for Health Links (THET)

This Monitoring and Evaluation toolkit provides a guide to monitoring and evaluation specifically for Health Links partners in developing countries and in the UK.

Twenty Tips to help prevent Medical Errors: Patient Fact sheet (AHRQ)

Patient fact sheet outlining the top tips for making health care safer for patients and the public.

Case study page no.

It can potentially be replicated with considerations for the health systems context.


A low resolution version of the toolkit is downloadable via the website. Hard copies are available to buy via the website. Access the THET home page: http://www.thet.org/ Access this toolkit: http://thet.org/wpcontent/uploads/2009/10/THET-M-andE-Toolkit.pdf Access the AHRQ complete range of resources at: http://www.ahrq.gov/qual/pstools.htm Access this resource at: Page 99 of 117

Action Area 10: Patient Safety Partnerships What is Patient Centered Health Care: A Review of Definitions and Principles (IAPO)

What you can do to make Health Care Safer: A Consumer Fact sheet (NPSF)

Purpose


IAPO has developed a review paper providing an introduction to the concept of patient-centred healthcare: outlining current definitions and principles; examples of research studies on its impact; and some barriers to its practice. It analyses the information, drawing out comments and questions pertinent to the concept of patientcentred healthcare. The aims of the resource are: to provide useful reference material on patient-centred healthcare - to stimulate thought and discussion and to assist in identifying and promoting the principles of patientcentred healthcare - to produce a Declaration on Patient-Centred Healthcare Encourages patient involvement in their treatment and the importance of patients receiving information. Outlines a series of steps which consumers can undertake to make sure they have a safer experience with the health care system.

Where to find

Case study page no.

http://www.ahrq.gov/consumer/20tips.p df Access this resource at: http://www.patientsorganizations.org/att ach.pl/547/494/IAPO%20PatientCentred%20Healthcare%20Review%20 2nd%20edition.pdf

http://www.npsf.org/for-patientsconsumers/tools-and-resources-forpatients-and-consumers/what-you-cando-to-make-healthcare-safer/

.


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Action Area 11: Patient Safety Funding Action Area 11: Patient Safety Funding

Purpose


Where to find

CostIt Software (WHO)

CostIt (Costing Interventions templates) is software designed to record and analyse cost data. It is not a datacollection tool but can guide the development of instruments for collecting primary data. The main function of CostIt software, completely automated, is to calculate the economic costs of interventions, however, it can also be used to estimate financial costs. Analysts wishing to use CostIt should be familiar with general cost concepts and have a basic knowledge of Excel software.

It provides a set of separate templates for the reporting and analysis of costs at the programme, hospital, primary health facility and household levels. Features of CostIt include a macro that automatically converts costs from any given year to those of the base year chosen by the analyst; and ability to adjust cost for different levels of capacity utilization. CostIt is a work in progress and will accordingly be updated in an ongoing manner with successive versions and a detailed user’s guide. Currently, only a brief user guide is available.

General information: http://www.who.int/choice/toolkit/cost_it/en/index .html From the general information page, you are directed to links to enable access to;  Programme level software,  Hospital level software  Primary health care facility level software,  Primary health care facility level completed software To access the simple user guide: http://www.who.int/choice/toolkit/Costit%20User Guide%20(version%204.5).PDF

Health Statistics and Health Information Systems Toolkit for Monitoring Health Systems Strengthening (WHO) The Business of Health in Africa – Partnering with the Private Sector to Improve Peoples Lives (IFC/World Bank)

See Action Area 1. The specific toolkit of relevance here is Health Systems Financing. The toolkit describes core indicators for the availability of funds, the extent of financial risk protection and how to use financial indicators for health system strengthening. This International Finance Corporation (IFC) report is a result of joint work with the Bill And Melinda Gates Foundation to explore the role of the private sector in meeting the need for more and higherquality health care in Sub- Saharan Africa. It also identifies policy changes that governments and international donors can make to enable the private sector to take on an ever more meaningful role in closing Africa’s health care gap. The report addressed the potential for complementary solutions and looks at what might be done to further leverage the private sector to

A range of tools are listed in the annex.

The report is targeted at governments, opinion-makers, multilateral agencies, donors, investors, and NGOs. The report is useful for consideration by those involved in strengthening patient safety since it addresses a number of the contextual issues existing across the health care sector in the region of Africa.


Case study page no.

Suggestions for modification or input from users are welcome and should be sent to [email protected] General information on the toolkit: http://www.who.int/healthinfo/statistics/toolkit_hs s/en/

http://www.unido.org/fileadmin/user_media/Servi ces/PSD/BEP/IFC_HealthinAfrica_Final.pdf

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The Economic Case: Implementing nearpatient alcohol handrub in your trust (NPSA)

Purpose

improve access to health care. It concludes with a case for investing in health care. Developed at the start of the NPSA cleanyourhands campaign, this document was prepared to facilitate NHS hospitals in estimating the likely costs and benefits of successful implementation of the multimodal hand hygiene improvement strategy.

The Scio-economic Burden of Hospital Acquired Infection (HPA)

This seminal study was commissioned by the Department of Health, UK, to determine the socio-economic impact of health care-associated infection across multiple levels of society, not only health care institutions.

Tools for System Change: Alcoholbased Handrub Planning and Costing Tool (WHO)

 To help managerial staff to provide alcohol-based handrub at the point of care  To decide on whether to purchase alcohol-based handrub from an established manufacturer, or to produce it locally according to WHO guidelines


Where to find

The economic case suggested that a hospital with 500 beds and 20,000 inpatient admissions would achieve a net steady-state cash saving of around £460, 00 per year. The quantitative results presented are subject to some uncertainty in several parameters, notably the extent to which increased hand hygiene can reduce health care-associated infection. However, the paper suggests that the intervention will be cost-saving even if the reduction in infection is as low as 0.1% The report provides useful information on how to determine the economic and social impact of health careassociated infection, and describes the results of the incidence of infection and financial costs to health care. It attempts to extrapolate these costs to the national level. Helps to ascertain the feasibility of implementing alcohol-based handrub Requires that information be gathered regarding all local producers of alcohol-based handrub and on regional & international distributors prior to use of tool

To access the resource visit the APPS Web Community Platform: http://ezcollab.who.int/apps


Case study page no.

A PDF of the report is available at: http://www.balticcare.org/Resources/BC_Riga.p df

http://www.who.int/gpsc/5may/tools/system_cha nge/en/index.html

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Action Area 12: Patient Safety Surveillance and Research Action Area 12: Patient Safety Surveillance and Research

Purpose


Where to find


This revised guidance on communicating effectively with patients when things go wrong is a best practice guide for all healthcare staff, including boards, clinicians and patient advocates. It explains the principles behind Being open and outlines how to communicate with patients, their families and carers following harm. This guidance and the associated actions outlined in an accompanying Alert, provide reassurance that Being open is the right thing to do, and encourage NHS boards to make a public commitment to openness, honesty and transparency. The full range of tools include: Webinars for clinicians; Webinars for Board members; an Alert; Supporting Information; a Framework and an elearning module. This document is aimed at policy makers, research commissioners and leading agencies involved in research for patient safety. It highlights the broad areas that have been considered essential targets for research on patient safety. The report emphasizes the need for research in developing countries to facilitate the design and testing of locally effective, affordable solutions to patient safety problems. The key message is that research in developing countries should be linked to action for improvement and development.


Access the entire range at: http://www.nrls.npsa.nhs.uk/resources/ ?entryid45=65077

The report describes the priorities for action to address some of the patient safety issues responsible for most of the burden of death and disability related to unsafe care in developing countries, such as counterfeit and substandard drugs, inadequate competency, training and skills, inadequate knowledge and knowledge transfer, substandard maternal and newborn care, healthcare-associated infections, inadequate understanding of the extent and nature of unsafe care, unsafe injection practices and unsafe blood practices. A number of the core indicators relate to APPS areas of assessment (e.g.

General information on Global Priorities for Research in Patient Safety: http://www.who.int/patientsafety/researc h/en/ Global Priorities for research PDF: http://www.who.int/patientsafety/researc h/priorities/global_priorities_patient_saf ety_research.pdf

Global Priorities for Research in Patient Safety

Guidance for Selecting and Using Core Indicators

MEASURE Evaluation is funded by the US Agency for International Development


MEASURE Evaluation home page: http://www.cpc.unc.edu/measure

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Purpose


Where to find

for Cross-Country Comparisons of Health Facility Readiness to Provide Services (USAID)

(USAID) and exists to develop, implement and facilitate methods for and approaches to improving health information systems, monitoring and evaluation (M&E), and data use; and collecting, sharing and disseminating information, knowledge, and best practices in order to increase the use of data and advance the field of health monitoring and evaluation in many countries. It provides technical leadership through collaboration at local, national, and global levels to build the sustainable capacity of individuals and organizations to identify data needs, collect and analyze technically sound data, and use that data for health decision-making. MEASURE Evaluation has developed simple, standardized core indicators for monitoring health facility assessment. This document forms part of the WHO Regional Office for Africa’s work in collaboration with the Centers for Disease Control and Prevention (CDC), USA and other partners is developing a regional strategy to strengthen national public health laboratories (NPHL). A particular emphasis is placed on providing laboratory data for high priority bacterial diseases including cholera, dysentery, meningitis and plague.

infrastructure, infection control, laboratory, and staffing and waste disposal)

Details of the Guidance: http://www.cpc.unc.edu/measure/tools/ monitoring-evaluation-systems/hfamethods

This guide is intended for the national ministry of health (MoH) laboratory focal point or chief officer who oversees all the laboratories in the country, the coordinator of the NPHLN, and the laboratory personnel. Other users of this guide may include IDSR focal persons at all levels, training officers, curriculum developers, and Ministries of Health and their partners. The laboratory focal person or chief medical officer can use this guide to develop a plan to establish or strengthen a NPHLN. This guideline can be used to advocate for political commitment and funding at national levels in support of laboratory strengthening to improve detection, confirmation, response, and prevention of priority infectious diseases. The guideline is also useful for

http://www.afro.who.int/en/divisions-aprogrammes/dsd/health-technologies-alaboratories.html

Guide for National Public Health Laboratory Networking To Strengthen Integrated Disease Surveillance and Response (IDSR) (WHO/CDC)


Case study page no.

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Purpose

Improving Data Quality – A Guide for Developing Countries (WHO)

This guide aims to provide a set of guidelines to enable healthcare workers, health information managers and administrators at all levels to focus on improving the timeliness, accuracy and reliability of health care data. The guidelines describe the activities that should be considered when addressing the question of data quality in health care, regardless of the setting.

Patient Safety Case Studies in Patient Safety Research Series (WHO)

 19 Web-based case studies designed to illustrate key examples of research and research methods in patient safety  To encourage early- to mid-career researchers and health care practitioners to pursue patient safety research This new, free on-line course starts in April 2010 to introduce the basic elements of Patient Safety Research. It is intended to assist in understanding the magnitude of the problem in hospitals and primary care facilities as a first step towards improving Patient Safety. The sessions will be provided by internationally renowned specialists in Patient Safety; Dr David Bates, External Program Lead for Research, WHO Patient Safety, and the Director of the Center of Excellence in Patient Safety and Research in USA, and Dr Albert Wu, a Professor in the Department of Health Policy and Management at Johns Hopkins University, USA.

Patient Safety Research: Introductory course (online) (WHO)


laboratory personnel so they know and comply with its objectives and content.  Although the emphasis might seem to be on hospitals and hospital medical records, these guidelines have been designed to address all areas in health care where data are collected and information generated. The reader is guided to assess and, where necessary, improve the quality of data generated in the environment within which they function, regardless of size, remoteness or sophistication. WHO describe the guide as an aide memoire rather than a definitive set of rules.  Includes examples of patient safety research from both the developed and developing world  Cases presented in Power Point format  Requires internet access All sessions will be broadcasted through the RAFT network (RAFT:Réseau en Afrique Francophone pour la Télémédecine) developed by the Geneva University Hospitals (HUG) in 2000 as well as with the application, GoToWebinar. French sessions will be launched in the near future. (sessions en français seront lancés dans un proche avenir). To follow the course, please click the URL listed in column 4. Participants need a computer with internet access and functioning speakers. One computer per group is also no problem. There's no need to


Where to find

Case study page no.

 Access the Guide: http://www.wpro.who.int/publications/do cs/Improving_Data_Quality.pdf

http://www.who.int/patientsafety/researc h/strengthening_capacity/classics/en/in dex.html

Session 1: What is Patient Safety? (Dr David Bates): http://www.who.int/patientsafety/res earch/online_course/en/index.html Session 2: Measures to improve patient safety: an overview (Dr David Bates): http://www.who.int/patientsafety/res earch/ps_online_course_session2_i ntro_english_2010_en.ppt Session 3: Measuring Harm (Dr Albert Wu): http://www.who.int/entity/patientsaf ety/research/ps_online_course_ses sion3_intro_english_2010_en.ppt Session 4: Understanding causes

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Purpose


Where to find

install any new applications on the computer.

(Dr Albert Wu): http://www.who.int/entity/patientsaf ety/research/ps_online_course_ses sion4_intro_english_2010_en.ppt Session 5: Identifying solutions and implementation (Dr Albert Wu): http://www.who.int/entity/patientsaf ety/research/ps_online_course_ses sion5_solutions_imp_2010_en.ppt Session 6: Evaluating Impact (Dr Albert

The sessions will run from April 2010 to May 2010.

Case study page no.

Wu): http://www.who.int/entity/patientsafety/r esearch/ps_online_course_session6_in tro_english_2010_en.ppt

Session 7: Translating Evidence into Safer Care (Dr Albert Wu): http://www.who.int/entity/patientsaf ety/research/ps_online_course_ses sion7_intro_english_2010_en.ppt Session 8: Knowledge Strengthening for Patient Safety (Dr Albert Wu):

RAFT Network (HUG)

Initially set up to provide telemedicine to francophone countries in West Africa. Distance continuing education seminars for Africa; 8 1-hour seminars covering science of patient safety, research, and how to translate research into practice. Teleconsultation tool enables virtual communities of care professionals to exchange advice about the management of clinical cases.

Available with low bandwidth therefore able to reach more remote areas. This is a tool to educate researchers about patient safety. And creates opportunities for bidirectional knowledge transfer. In terms of challenges:  Unable to use more sophisticated tools (e.g. videos) due to low bandwidth.  Technology issues (internet access). Requires reliable source of electricity.


http://www.who.int/entity/patientsafety/r esearch/ps_online_course_session8_in tro_english_2010_en.ppt Links to session 1 -8 Changed 12/2011 http://raft.hcuge.ch/

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http://raftadmin.blogspot.com/

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Purpose


Where to find

Case study page no.

 Research Information Booklet

General information resource on research and patient safety

7 Steps range (NPSA)

A guide for staff who provide care in the NHS, England, and for those involved in risk management and clinical governance. The 7 Steps centre on culture, leadership, integration of risk management, promotion of reporting, patient involvement, learning and sharing and implementation.

Program primarily for francophone countries. Lists areas where research is needed to reduce patient harm. Describes the studies undertaken in twenty-six hospitals from eight countries in the Middle East and Africa and 58 hospitals from five countries in the American region which focused on 30 000 patients’ reviews and analyses. Useful information which can be modified for planning patient safety improvements in each of the 7 areas. The summary document can be used as a quick reference manual.


http://whqlibdoc.who.int/hq/2009/WHO_ IER_PSP_2009.10_eng.pdf

NPSA general website: www.npsa.nhs.uk The 7 Steps range includes a generic resource, a summary document, a resource tailored to mental health and a resource tailored to primary care, available at http://www.nrls.npsa.nhs.uk/resources/ ?entryid45=59787&q=0%c2%acseven+ steps%c2%ac

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Level 3

Case Studies Level 3 describes situations where the resource has been utilized in a health care context, presenting the user with additional information to assist in their choice of resource. This section of the Resource Map will expand over time to include case studies from APPS partnership hospitals. To add your case study to this action area send to [email protected]

Action Area 1: Patient Safety and Health Services/Systems Development To add your case study to this action area send them to [email protected] Action Area 1: Patient Safety and Health Services/Systems Development

Case Study


York Hospitals NHS Trust, UK, focused on getting the right team in place, both centrally and at ward level. The deputy CEO described his team as “passionate about risk reduction and expert in their field”. The central team offer support rather than act as inspectors. They understand the issues and do not criticise staff on the front line. Creative use of two vacancies in the organization enabled the hospital to use 10 staff from a range of clinical directorates for 1 day each week, “Effectively I got 10 full time people as they took awareness of risk back to their frontline jobs” (CEO). West Middlesex University Hospital: acutely ill patients and the introduction of a head of patient safety position. The action plan drawn up in response to the LIPS course focussed on highlighting the deterioration of acutely ill patients, an area which the trust felt was a priority, with the aim of decreasing admissions to ITU/ HDU. Working with one ward, the team planned firstly to improve the accuracy and timeliness of observations and secondly to improve communication via the introduction of the SBAR. The ward matron, who did not attend LIPS, was enthusiastic and assisted in the amendment of the audit form to relate to the observation chart and put the required metrics in place in collaboration with the clinical risk manager. Outcome measures included: the number of crash calls; and the number of patients who went on to be admitted to ITU/ HDU. They audited their observation practices and found that fields such as pain score were not being adequately completed. Baseline data was recorded, however ward staff have not yet achieved 95% compliance and therefore, in line with LIPS practice, have not moved further down the line in implementing their action plan. Instead, the necessity of additional capacity to support improvements in patient safety was recognised, and a

Leading Improvements in Patient Safety (NHSI)


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Leading Improvements in Patient Safety (NHSI)

7 Steps range (NPSA)

Case Study

business case for a new head of patient safety position was developed and put to the board. This position will provide the necessary capacity and momentum to implement much of the trust’s LIPS learning. The business case was approved by the executive, and the trust is currently in the process of restructuring within the governance and risk department. In the interim, resources have been allocated to introduce the Global Trigger Tool (GTT). The original action plan has been merged with the Productive Ward activity where impressive improvement has been made with patient observations, the acknowledged difference between the approaches being the presence of a project facilitator and dedicated clinical leadership of this project. The Productive Ward programme is now rolling-out across a further two wards every 3 months. In addition, at board level, director portfolios have been reorganised to release additional time for the director of nursing and midwifery and the medical director to focus on patient safety and a new position of director of service transformation is leading on lean methodologies to plan and sustain changes in practice. The lack of capacity of the nursing and medical directors to personally deliver the action plan was felt to be the key challenge faced by the project team, particularly in winter months which saw the hospital under considerable pressure. Heart of England NHS Foundation Trust: strategic safety plan: Upon attending LIPS, Heart of England was already planning and undertaking a wide range of initiatives aimed at improving patient safety within the trust. They therefore decided to use their opportunity for action planning during the LIPS course, developing a safety plan that unified these activities and identified any gaps through focusing on the strategic level. The strategic plan has three related foci:  Measuring for patient safety  Ensuring consistent practice  Changing organisational culture These are operationalised via a number of improvement actions drawing on tools and techniques from the LIPS course which are being introduced on a rolling basis. The first ‘quick win’ actions are the introduction of:  Patient safety walkabouts  The SBAR communication tool  The Global Trigger Tool (GTT) The patient safety walkabouts are up and running; the SBAR has been trialled using a PDSA cycle and is currently being rolled out on a ward by ward basis across the trust; and the GTT is currently being trialled. The next area to be focussed on will be the standardisation of test results and reporting pathways. These will be supported by further refinement of the strategic plan. The challenges faced in implementing the strategy related to the enthusiasm amongst colleagues for the SBAR which actually presented some challenges for the project team. The apparent simplicity of the tool and the potential benefits of its introduction have led to demand for a swift, trust-wide implementation. The project team have worked to explain the need for appropriately staged implementation, first trialling the tool, seeing how it works in practice, and the resources and processes required for its successful utilisation. Creating the ‘dedicated capacity’ to focus on the operationalisation and delivery of the strategic plan has also been a challenge, particularly in terms of the time required to successfully utilise the GTT. Key to overcoming these challenges has been the support of executive colleagues who have taken ownership of the patient safety agenda and made resources available in the form of staff posts to make the delivery of the plan a reality. Working with ‘champions’ and being realistic about the timescales necessary to implement improvement actions has also been helpful. Gateshead Health NHS Foundation Trust, England, UK used NPSA Seven Steps as a basis for the development of its long-term strategy; Safecare, A responsibility we ALL share. The strategy includes six concise commitments: i) The establishment of a SafeCare Council chaired by both the Medical Director and Nurse Executive Director. The Council acts as the conscience of the organization, constantly asking “are we constantly improving the care we deliver?”; ii) The design and implementation of a local SafeCare campaign to engage patients, clinical and nonclinical staff; iii) The establishment of an accountability framework, with organizational teams trained in root cause analysis, problem solving and data analysis; iv) Sharing of good practice through local alerts and bulletins and encouraging reporting; v) Greater openness with patients and their families re risk and error; vi) Education and training prioritised.


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Action Area 2: Links with National Policy on Patient Safety To add your case study to this action area send them to [email protected] Action Area 2: Links with National Policy on Patient Safety

Case Study

Professionalism – dilemmas and lapses (NCAS)

The guide contains case studies (fictitious) which have been used at NCAS workshops and also at annual conferences. The material is presented to provide the basis for postgraduate education meetings and seminars. They are intended to help in the exploration of the dilemmas faced in dealing with performance concerns and to identify approaches to assist in their management. Available at http://www.ncas.npsa.nhs.uk/trainingandevents/conferences/conference-reports/case-studies/ EVIPNet success stories in Africa are available: http://www.evipnet.org/php/level.php?lang=en&component=102&item=18 Focusing on stories from Burkino Faso, Uganda and Cameroon Burkino Faso: After policy dialogue, the ministry of health decided to include proposed policy options in the 7th Global Fund project. The implementation process started already as a pilot for the lay health workers activities in 3 districts and to fully implement options to engage the private sector in adhering to national guidelines about subsidized drugs in all settings (pharmacies, clinics) and to ban monotherapies. After M&E of the pilot projects the lay health worker options a large scale implementation of lay health workers activities will be included in the 8th proposal to GFATM. Uganda: Uganda national policy dialogue held in the end of March for the updated policy brief. Senior policymakers decided to include the policy brief among the resource documents being used to develop the National Health Plan (2009) which in turn informs the Health Sector Strategic Plan (2010-2015) Cameroon: After policy dialogue, all three options of the policy brief were accepted into the Malaria Control Program of the country.

EVIPNet (WHO)

Action Area 3: Knowledge and Learning in Patient Safety To add your case study to this action area send them to [email protected] Action Area 3: Knowledge and Learning in Patient Safety

Case Study


York Hospitals NHS Trust, UK, focused on getting the right team in place, both centrally and at ward level. The deputy CEO described his team as “passionate about risk reduction and expert in their field”. The central team offer support rather than act as inspectors. They understand the issues and do not criticise staff on the front line. Creative use of two vacancies in the organization enabled the hospital to use 10 staff from a range of clinical directorates for 1 day each week, “Effectively I got 10 full time people as they took awareness of risk back to their frontline jobs” (CEO).  Participating hospitals include Hôpital Central de Yaoundé (Cameroon), Hôpital Universitaire du Point G (Mali), Hôpital Universitaire Le Dantec (Sénégal)  The RAFT network was successfully implemented in Mali to allow for North-South, South-South, and South-North distance learning and teleconsultations ( see Geissbuhler A, Bagayoko CO, Ly O. The RAFT network: five years of distance continuing medical education and tele-

RAFT Network


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Action Area 3: Knowledge and Learning in Patient Safety Safe Surgery Checklist (WHO)

Case Study

consultations over the Internet in French-speaking Africa. International Journal of Medical Informatics 2007; 76: 351-6 http://raft.hcuge.ch/06-04-29%20RAFT%20english.pdf). Checklist was successfully piloted in 8 hospitals in 8 cities (including Ifakara, Tanzania). After introduction of the checklist, hospitals experienced lower death rates, and lower rates of inpatient complications. Detailed information can be found at: http://content.nejm.org/cgi/content/full/NEJMsa0810119

Action Area 4: Patient Safety Awareness Raising To add your case study to this action area send them to [email protected] Action Area 4: Patient Safety Awareness Raising

Case Study

Patients for Patient Safety Workshops (WHO) Patient Safety Champions (WHO) Patient Voices Videos (WHO)

• Workshops have resulted in the creation of patient-policymaker partnerships • Example of Patient Safety Champion Evangelina Vazquez-Curiel from Mexico - now working with Mexican government on teaching hand hygiene; working on newborn screening committee; travels to speak & raise awareness about patient safety • Evaluation form given to workshop participants indicated that videos rank high as the most powerful, most educational, most appropriate tool for patient safety education • Much anecdotal feedback about efficacy of videos • Videos requested by a Mexican government official to be shown within the Mexican government

Action Area 5: Health Care-Associated Infections To add your case study to this action area send them to [email protected] Action Area 5: Health Care-Associated Infections

Case Study

Clean Safe Care (Department of Health)

A wealth of case study material is available at: http://www.clean-safe-care.nhs.uk/index.php?pid=27


Case studies are available from Brazil, Bulgaria, Egypt, India, Indonesia and the UK. Brazil: A full campaign of education and mobilization for hand hygiene was instituted in the whole network of hospitals in which the company


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Case Study

operates. Altogether more than 500 professionals were involved. The main goals were promoting theoretical and technical knowledge about the importance and practice of hand hygiene through demonstrations and guidelines among all network staff and patients. Increasing compliance with hand hygiene among health care workers and a general call to action highlighting the risks of non compliance with hand hygiene were other aims. As a result of the campaign they have established the group "Happy Nursing", to make a close, good-humoured and a direct approach of the subject, with group demonstrations of different techniques for hand hygiene, distribution of free samples of soap, brochures and guidelines; lectures and refresher training every month; stickers designed with step-by-step instructions for each method of hand hygiene, to be fixed in bathrooms, near sinks and in patient care areas; and the distribution of posters and folders with the "5 Moments for Hand Hygiene" recommended by WHO. Key barriers associated with the campaign related to finding extra-qualified professionals to work simultaneously in 8 hospitals. The solution was the recruitment of the "Happy Nursing" team. An additional barrier was raising funds and approving budgets within hospitals to produce custom soaps and brochures. This was overcome through partnerships with suppliers and printers. A third barrier was the full implementation of the campaign without affecting the progress of other consulting activities in all hospitals and this was addressed through use of volunteers and participation of the "Happy Nursing" team. The key learning point from Brazil relates to the need for a good-humoured approach combined with some demonstration and technical lessons brings awareness to this subject and great results. Board directors and executive managers from big hospitals and clinics took part in the campaigns recognizing the importance of the initiative and were introduced to the guidelines and the techniques of hand hygiene In Egypt a campaign was undertaken to increase the compliance of health-care staff with hand hygiene, in particular after the shift to the use of alcohol-based products. The initiative was targeted to ICU. A hand hygiene campaign was undertaken over one month (April 2009) in which a pocket bottle was designed with alcohol gel and an observation sheet was formulated focussing on the 5 moments. This was started after an orientation lecture in which we explained the WHO recommendations for hand hygiene. The main problem was the supply of the alcohol-based product, but was overcome by having the alcohol gel as donation from one of the companies in Cairo, who consider much to share in an activity through this organization. The learning has resulted in one of the ICUs revising the relatively poor compliance using the method of pocket bottle. However the overall the compliance of hand hygiene was excellent and the implementation of the 5 moments was perfect especially for moment 3. Implementation of moment 2 needs to be reinforced as well. Further information on case studies can be found at: http://www.who.int/gpsc/5may/share/case_studies/en/index.html In addition, results of the field testing related to the implementation of the WHO Multimodal Strategy in Mali are now available: Successful implementation of the world health organization hand hygiene improvement strategy in a referral hospital in Mali, Africa. Allegranzi B, Sax H, Bengaly L, Richet H, Minta DK, Chraiti MN, Sokona FM, Gayet-Ageron A, Bonnabry P, Pittet D; World Health Organization "Point G" Project Management Committee. Infection Control and Hospital Epidemiology 2010 Feb; 31(2): 133-41.

Infection Prevention Guidelines for Health Care Facilities with Limited Resources(JHPIEGO)

For copies of the paper contact [email protected] MOZAMBIQUE: In close collaboration with the Mozambique Ministry of Health (MOH) and other partners, JHPIEGO has been working to reduce health worker and client exposures to blood-borne pathogens. Through a hands-on approach based on the standardization of care, this initiative has been successfully implemented in 23 hospitals, and is currently being expanded to the remaining 10 hospitals in the country. As part of this effort, JHPIEGO is developing workplace safety and health guidelines, including occupational post-exposure prophylaxis (PEP) for HIV, as well as IPC training materials and job aids for ancillary workers. JHPIEGO is also providing technical assistance to improve the sterilization and waste management systems in U.S. Government-supported HIV/AIDS treatment sites throughout the country.


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Case Study ZAMBIA: JHPIEGO and partners are implementing the President’s Emergency Plan for AIDS Relief (PEPFAR) program to prevent medical transmission of HIV in Zambia. As part of this effort, JHPIEGO led the Prevention of Medical Transmission of HIV in Zambia Program, spearheading the assessment and pilot-testing of IPC and injection safety strategies, as well as assisting the Zambian government in the development, production and dissemination of national IPC guidelines and the Zambia National Infection Prevention Implementation Strategy 2005-2007. The program has assisted district- and facility-level managers in the forecasting, procurement and management of essential IPC supplies, resulting in improvements in quality of care at key facilities in Zambia. JHPIEGO continues to support the Zambia government in scaling up improved injection safety and IPC programs nationwide in all nine provinces and 72 districts. MALAWI: In 2001, JHPIEGO helped Malawi's MOH and Population and National Quality Assurance Task Force to develop national IPC standards. The standards were implemented at seven pilot hospitals, which resulted in dramatic (more than two-fold) improvements in IPC practices in just over a year. Since then, the program has expanded to 24 health facilities, covering 20 districts across all three regions of Malawi. As part of this initiative, an IPC "logo and recognition" process has been initiated—through JHPIEGO’s SBM-R approach—whereby hospitals are officially recognized for their level of compliance with established, IPC-related performance standards. Impressed with the success of this effort, the MOH now requires all organizations working to strengthen IPC in the country to use the SBM-R approach. In addition, other countries in Africa are planning to adopt the same approach to strengthening the IPC component of their health systems. INDONESIA: In response to the global threat of an avian flu pandemic, JHPIEGO is assisting the Government of Indonesia in developing and disseminating national IPC standards and guidelines specific to avian flu, based on proven best practices, for various cadres of healthcare workers and support staff. To complement this effort, JHPIEGO is also helping to develop, disseminate and implement a national IPC strategy to prepare for, and respond to, an outbreak or epidemic of this disease. The strategy covers acquiring essential IPC equipment and supplies, training health care staff in IPC, and adhering to IPC-specific models of facility management and supervision. ETHIOPIA: JHPIEGO assisted Ethiopia's MOH in developing national IPC guidelines, which have been disseminated to all of the country's health facilities. To date, providers at 89 hospitals have been trained in IPC, most sites now have IPC committees, and trained providers are orienting the other staff at their facilities to various components of IPC. JHPIEGO also assisted the MOH in developing performance standards for prevention of mother-to-child transmission of HIV, of which IPC performance standards are a critical component. In addition, JHPIEGO is working with the MOH to strengthen national preparedness for a potential outbreak of avian flu. As part of this effort, JHPIEGO is supporting the development of a national avian flu training package and training of emergency operating center staff in selected regions.

Action Area 6: Healthcare Worker Protection To add your case study to this action area send them to [email protected] Action Area 6: Healthcare Worker Protection

Case Study

No case study exists at present

To add your case study to this action area visit the APPS Web Community Platform: http://ezcollab.who.int/apps The web platform contains a case study folder within the Library, and a template feedback from.


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Action Area 7: Healthcare Waste Management To add your case study to this action area send them to [email protected] Action Area 7: Healthcare Waste Management

Case Study



Action Area 8: Safe Surgical Care To add your case study to this action area send them to [email protected] Action Area 8: Safe Surgical Care

Case Study

Surgical Safety Checklist (WHO)

Checklist was successfully piloted in 8 hospitals in 8 cities (including Ifakara, Tanzania). After introduction of the checklist, hospitals experienced lower death rates, and lower rates of inpatient complications. Detailed information can be found at: http://content.nejm.org/cgi/content/full/NEJMsa0810119

Action Area 9: Medication Safety To add your case study to this action area send them to [email protected] Action Area 9: Medication Safety

Case Study

Potassium chloride Alert 01 (NPSA)

University College of London (UCL) Hospitals NHS Trust reported that the Alert enhanced the credibility and authority of the Head of Pharmacy providing a framework to implement an important patient safety improvement. The organization welcomed the national guidance as an aid to local action. The Alert reportedly enabled action on an existing poorly controlled clinical risk, allowing for risk reduction measures, increased understanding and assessment of clinical areas where the risk persisted. UCL started by undertaking an assessment of use in all clinical areas, Removing potassium chloride from areas where it was not needed and from areas where it could be replaced with pre-prepared solutions containing potassium. Clinical pharmacists were central to the success of reviewing and challenging the continued need for potassium chloride ampoules in clinical areas. The drug was eventually written into the organizations controlled drug policy. “Our philosophy is to be self auditing.


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That way we are one step ahead all the time”.

Action Area 10: Patient Safety Partnerships To add your case study to this action area send them to [email protected] Action Area 10: Patient Safety Partnerships

Case Study



Action Area 11: Patient Safety Funding To add your case study to this action area send them to [email protected] Action Area 11: Patient Safety Funding

Case Study



Action Area 12: Patient Safety Surveillance and Research To add your case study to this action area send them to [email protected] Action Area 12: Patient Safety Surveillance and Research

Case Study

Guidance for Selecting and Using Core Indicators for Cross-Country Comparisons of Health Facility Readiness to Provide Services (USAID)

The potential for using the core indicator data for action was demonstrated in the subsequent uptake of the Kenya HFC by the Kenya Ministry of Health. A preliminary report of the study was disseminated to all health ministry department heads, the permanent secretary, divisional heads, senior program managers, and relevant district health management teams.The data were utilized in a wide range of contexts, specifically including the following:  The United Nations Population Fund, Family Health International, Kenya National AIDS and STD Control Program, Reproductive Health, National Land Transport Program, and malaria-control programs have used the report to scale-up services in health facilities.  The Kenya Ministry of Health has encouraged all districts to develop annual operational plans and use thematic maps, including census results, to develop their annual operations plans, which went into effect in July 2006.  A national team within the Kenya Ministry of Health used technical and financial support from WHO to train at least two people in every


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RAFT Network

Case Study

province as training-of trainers for health mapper and GIS.  Kenya Ministry of Health used the report to justify employing more technical staff.  The Population Council used part of the census results to complete a Kenyan service assessment.  The national Kenyan HMIS included part of the census results in its annual performance report.  HMIS used HealthMapper to map areas that have been having epidemics.  Participating hospitals include Hôpital Central de Yaoundé (Cameroon), Hôpital Universitaire du Point G (Mali), Hôpital Universitaire Le Dantec (Sénégal)  The RAFT network was successfully implemented in Mali to allow for North-South, South-South, and South-North distance learning and teleconsultations ( see Geissbuhler A, Bagayoko CO, Ly O. The RAFT network: five years of distance continuing medical education and teleconsultations over the Internet in French-speaking Africa. International Journal of Medical Informatics 2007; 76: 351-6 http://raft.hcuge.ch/06-04-29%20RAFT%20english.pdf ).


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