docQuality and Safety along the Health and Social Care Continuum
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Quality and Safety along the Health and Social Care Continuum
The International Society for Quality in Health Care 31st International Conference Quality and Safety along the Health and Social Care Continuum 5th - 8th October 2014 Windsor Barra Conference Centre, Rio de Janeiro, Brazil Abstract Book Poster presentations 1145 -‐ Quality Improvement Through International Accreditation Programme In Indonesia 1224 -‐ How Can We Take Into Account Effort, Excellence And Uncertainty When Rewarding Quality In Hospitals: A French Initiative Of P4P Program 1229 -‐ Validation Of An Indicator Assessment Tool For Accreditation: Identifying Hand Hygiene Compliance Rates As A Process Indicator 1255 -‐ Applicability Of Tools Used By The Hospital Manager 1282 -‐ Introducing And Promoting Community-‐Based Mental Healthcare Model Through Accreditation 1299 -‐ Evaluation Of Health Services: The Roadmap Of PNASS Applied In Surgical Centre 1462 -‐ A Study Of Large Hospitals' HSMR (Hospital Standardised Mortality Ratio) In Korea 1486-‐ Accreditation And Improvement In Process Quality: A Nationwide Study 1498 -‐ Adequacy Of Health Services Of A Private Health Plan: How Accreditation Can Contribute -‐ An Innovation In Brazil 1668 -‐ The Dental Field And The Promotion Of Quality, Safety And Evaluation Of Practice 1670 -‐ Practice And Theory In Health Service Accreditation Standards Development: Does The Reality Match The Rhetoric? 1864 -‐ Accreditation Of Dialysis Centres: Qualitative Analysis Of Its Impact In Argentinian Facilities. 1900 -‐ Using Advanced Technology To Support Clients, Assessors And Staff Through Accreditation 1986 -‐ Validation Of Patient Safety Indicators In The French Context 2011 -‐ A Decision Framework As A Critical Enabler For Improving Consistency Of Inspector’s Findings 2094 -‐ The Evolution Of Brazilian Public Hospitals In Process Improvement Of Quality And Safety 2117 -‐ The Accreditation Canada Stroke Distinction Program: A System Approach To Excellence 2194 -‐ Embedding Patient Safety Into The Accreditation Canada Emergency Medical Services Program 2197 -‐ The Evolution Of Healthcare Accreditation Standards: Are Principle-‐Based And Outcome-‐Focused Standards Feasible? 2223 -‐ National Healthcare Facility Licensing And Accreditation System – Establishment Stage 2380 -‐ Disease-‐Specific Evidence Of Higher Quality Of Care In Accredited Hospitals: In The Case Of Acute Heart Failure 2491 -‐ High Performance In Accredited Hospitals 2513 -‐ Towards A Culture Of Innovation In Health And Social Services 1150 -‐ The Effect Of Government Supervision On Quality Of Smoking Cessation Counselling In Midwife Practices 2391 -‐ Quantity Of Accredited Hospitals In Brazil 2531 -‐ Application Checklist For Self-‐Evaluation Of The Intensive Care Unit 1203 -‐ Integration Of Clinical Guidance, Quality Assurance And Research Activity In Danish Primary Care 1488 -‐ Cost-‐Effectiveness Of Dabigatran And Rivaroxaban Versus Warfarin In Management Of Non-‐ Valvular Atrial Fibrillation In Estonia 1572 -‐ Establishing Electronic Database For Conservation Of Birth Records Spreading Over 7 Decades 1742 -‐ Implementation And Assessment Of A Nursing EMR System In Taiwan 1764 -‐ Comparison Between Manual And Automated Methods For Erythrocyte Sedimentation Rate (ESR): A Tertiary Care Hospital Study 2561 -‐ Computerised Of Diagnosis For Patients Sumaré State Hospital, Brazil: Development Of A System For Remote Report For Investigations Pathology 1989 -‐ Evaluation Of The Effectiveness Of Information Technology In The Medical Process 1034 -‐ The Advantages Of Accepting Interns Of The Health Information Manager Program For Trainers In Practical Training Sites 1039 -‐ Student-‐Led Quality Improvement: A 3-‐Year Follow Up Study Of Kleihauer Testing And Anti-‐D Administration 1204 -‐ Can Prognostic Measurement Tools Automatically Be Applied Across Health Care Settings And Populations? 1276 -‐ Strategic Implementation Of Root Cause Analysis Education Program Enhances The Safety Climate In A Healthcare Organisation 1354 -‐ Are Referral Information And Discharge Diagnosis Compatible? 1411 -‐ Nutrition Core Competencies: A Foundation For Pre-‐service And In-‐service Nutrition Training 1475 -‐ Patterns Of Antibiotic Use In Paediatric Outpatients With Acute Upper Respiratory Tract Infections In Korea From 2009 To 2011 1490 -‐ Impact Of A Short Protocolized Institutional Training On Adequacy Of Time Of Interventions In Septic Patients: A Before And After Study 1586 -‐ Trends In The Rates Of Complications, Failure-‐To-‐Rescue And 30-‐Day Mortality Among Surgical Patients In New South Wales, Australia (2002 To 2009) 1725 -‐ Needs Assessment In Clinical Nursing Service Of Teacher Education 1822 -‐ Using Smart Objectives Management To Build High Quality Of Cancer Care 1854 -‐ Software Used By Brazilian Consortium Accreditation In Educational External Evaluation 1860 -‐ How To Improve The Commitment Of Clinical Staff To Accreditation? 1936 -‐ Patient Rating Tendency And Satisfaction With Care: Do Patients’ Inherent Rating Tendencies Affect Inpatient Satisfaction With Care Scores? 2016 -‐ Suicide In Older People Who Are Living In Community 2077 -‐ Knowledge, Attitudes And Practices Of Health Care Workers Towards Needle Stick Precaution At The Medical Centre In Taiwan 2173 -‐ The Prevention Of Preventable Death And Permanent Dysfunction After Internal Bleeding 2260 -‐ Student Lead Quality Improvement Projects Lead To Improved Patient Care In A Real World Setting 2293 -‐ The Experience Of Effectiveness Of Individualised Health Education By Pharmacists On Community Pharmaceutical Care 2306 -‐ "Institutional Training" 2366 -‐ Alcohol Use Prevention Project For Adolescents 2469 -‐ A Cohort Study On A Comprehensive Training Program For Enhancing Staff Competence In Prevention Of Unplanned Extubation In Ventilator Ward 2483 -‐ Developing Competencies To Improve Quality: Experience With Undergraduate Nursing Students In Applying PDCA Cycle And Using It In Care Management 1335 -‐ The Global Comparators Project: Hospital Mortality In 5 Countries 1615 -‐ Investigating Adverse Event Free Admissions In Medicare Inpatients As A Measure Of Patient Safety 1770 -‐ Performance Evaluation Form For Teachers Of CBA: A Study Of Usefulness, Suitability And Accuracy 1889 -‐ Culture Of Patient Safety In An Unit Oncology Of Hospital Accredited: Perception Of The Professional Nurse 1971 -‐ Innovative Strategies For Continuing Education In UniMed Paulistana 1228 -‐ Reliability And Validity Of The Brazilian Version Of The Hospital Survey On Patient Safety Culture 1232 -‐ Maximise The Societal Impact Across Various Socio-‐Economic Classes In The Developing World By Expanding A High Quality Lab-‐Testing Network Resulting In Ease-‐Of-‐Access 1246 -‐ Performance Indicators Used Internationally To Report Publicly On Healthcare Organisations And Local Health Systems 1417 -‐ The Hospital Manager’s Part In Quality Of Care And Patient Safety: A Systematic Literature Review 1443 -‐ Quality In Nursing – Nurses’ Perspectives On The NNN Taxonomies 1477 -‐ Key Functions And Recommendations On Reporting And Learning Systems For Patient Safety Incidents Across Europe 1529 -‐ Team Effectiveness In Clinical Networks: The Importance Of Team Inputs, Participation, And Presence Of Conflict 1544 -‐ Korea's Specialty Hospital System 1632 -‐ The Present Situation And Future Trends Of Hospital Accreditation In Mainland China 1637 – Co-‐operative Leadership In The Implementation Of Quality Systems: Structure, Process And Outcome Relationships 1740 -‐ Management By Walk Rounds In A University Hospital: Deployment And Evaluation Of Visiting Managers’ Satisfaction 1885 -‐ Performance Monitoring Of Group Practices In Hungary 1922 -‐ Do French General Practitioners Use Quality Indicators Results To Refer Their Patients To Hospitals? 2166 -‐ Malaysian Patient Safety Goals -‐ Singular Benchmarking In Malaysian Healthcare 2203 -‐ Establishment Of Guidelines For Safe Invasive Procedures 2213 -‐ Job Dissatisfaction And Turnover Intention Of Contract Nurses In Hospitals In Guangdong Province In China 2225 -‐ Patient Satisfaction Survey In Hong Kong – A Tool To Engage Staff And Patients For Quality And Patient-‐Centred Care 2360 -‐ No Fault Competition For Blood Sampling (Venipuncture) Related Adverse Events: Attitude Of The Japanese Medical Institutions 2388 -‐ A Pilot Study Of Workplace Violence Experienced By Nursing Personnel 2389 -‐ Working Around ‘The Clocks’: Nurses’ Responses To Electronic Overdue Medication Alerts 2412 -‐ Satisfaction Of Mothers With Childcare Services Provided At Public Institutions In Japan: The Association Of Socio-‐Economic Factors 2478 -‐ Awareness And Improvement Of Patient Safety Culture In A Newly Established Local Community Hospital Using The Questionnaire From SAQ And AHRQ 2525 -‐ Using Risk Scores To Identify Vulnerable Populations: A Case For LDL Cholesterol 1149 -‐ The Effect Of Government Supervision On Quality Of Integrated Care And Diabetes Type 2 Health Outcomes: A Cluster Randomised Controlled Trial 1234 -‐ Hospital Mortality In Selected Brazilian Hospitals: Do Primary Payer Status And Public-‐Private Partnerships For Financing Hospitals Affect Quality? 1881 -‐ São Camilo Hospital Score For Predicting The Long Term Hospital 2114 -‐ The Impact Of The Management Of Beds Based On Lean Six Sigma Methodology 2332 -‐ Pharmacist Presence In National Health System Hospital Network In The State Of Rio De Janeiro 2499 -‐ Practical Implementation Of A Clinical Case In The Selection Of Nursing Technicians 2514 -‐ Development Program Nurse -‐ The Challenge Of Attracting The Best Professional 2511 -‐ The Presence Of Nurses In The Management Of Beds In The Admission Patients Area 1182 -‐ Strategies To Facilitate Implementation And Sustainability Of Large System Transformations: A Case Study Of A National Program For Improving Quality Of Care For Older People 1192 -‐ Limited Effect Of Information Technology Support To Improve Handover From Hospital To Primary Health Care 1436 -‐ Have You SCAND MMme Please? To Prevent Harm In Older Emergency Medical Admissions To Acute Hospitals 2262 -‐ Using Action Research To Promote Compliance With Health Examination For Rural Residents 2321 -‐ The Quality Standards For Health Care Services Provided In Turkey 2325 -‐ Does Caregivers Have Different Health Related Quality Of Life? 2330 -‐ A Modified Delphi Methodology To Gain Consensus On Assessing Frailty In Acute Care 2423 -‐ Implementing A Long Term Care Accreditation Program 1083 -‐ Improving Weaning Rate Of Prolonged Mechanical Ventilation 1087 -‐ Lost In Translation? The Implementation Of Lean In Hospitals As A Multi-‐level And Multi-‐faceted Process. A Mixed Method Study Of Local Pre-‐conditions For Improvement 1100 -‐ The Characteristics And Risk Factors Of Unexpected Out-‐Of-‐Hospital Cardiac Arrest Within 72 Hours After Emergency Department Discharge 1131 -‐ Implementing Successful Hand-‐Hygiene Program: Prospective Study 1147 -‐ Evaluation Of The Quebec E-‐Health Record Medication Functions -‐ Potential Benefits And Barriers To Its Realisation According To Early Users Of The Technology 1158 -‐ Implementation Of Venous Thromboembolism Prophylaxis Protocol In A Tertiary Care Hospital 1176 -‐ To Improve Nurses And Caregivers Compliance To Modified Diet And Fluid Consistencies To 100% In Ward 73 Within Six Months 1226 -‐ Development Of Treatment Protocol For Hypoglycaemia Adult Inpatients 1251 -‐ Appraisal And Major Revision Of No-‐Fault Based Compensation / Causal Investigation System For Cerebral Palsy 1268 -‐ Enhancing Quality And Patient Safety By Designing And Complementing Medication Management With A Clinical Decision Support System In An Academic Hospital Of Pakistan 1277 -‐ Sepsis Kills -‐ But Not In New South Wales, Australia 1293 -‐ Toolkit: Catalogue Of Infection Prevention Measures To Decrease Risk Associated With An Indwelling Urinary Catheter And Achieved Results 1298 -‐ Tracking The Specimen Workflow By Using Barcode Specimen Tracking System To Improve The Safety Of Patient’s Specimens 1302 -‐ Exploring The Relationship Between Hospital Innovation Activities And Organisational Performance 1303 -‐ Improving Daily Life Independency To Post-‐Rehabilitated Stroke Patients: Scoring By Barthel Index 1304 -‐ Healthcare Quality Indicator Improvement Project Reduction Of Unplanned Re-‐Admission Rate 1309 -‐ Adherence To The Surgical Safety Checklist: A Cross-‐Sectional Survey At The 97Th Annual Meeting Of The Swiss Society Of Surgery 1344 -‐ Towards Resilience: The Evolution And Unveiling Of A New Improvement Science Model 1379 -‐ Quality Analysis Of Chinese Health Information Websites 1453 – Staff Experiences Of Implementation Of Standardised Handover Improvement Tools In The Post Anaesthetic Care Unit 1497 -‐ The Use Of The Hospital Survey Of Patient Safety Culture In Europe 1521 -‐ Risk And Clinical Management Protocols: An Interface In Quality Improvement And Patient Safety 1527 -‐ Hospital Staffing And Hospital Acquired Conditions In Colorectal Surgery 1530 -‐ Iatrogenic Prescription In Oncology: Application Of The Oncology Trigger Tool 1533 -‐ A Population Based Study Of The Secular Trends Of Cardiopulmonary Arrest And Mortality And Their Association With Rapid Response System Expansion 1547 -‐ Decrease The Failure Rate Of Pap Smear Test For Cervical Cancer Screening 1552 -‐ Decrease The Incidental Re-‐insertion Rate Of Nasogastric Tube In Homecare Patients 1578 -‐ Discrepancies During Time-‐Out – An Analysis Of Over 130.000 Surgical Checklists 1609 -‐ How Time Consuming Is The Surgical Team-‐Time-‐Out? 1630 -‐ The Implementation Of Team Resource Management (TRM) To Achieve Complete Post-‐Operative Handover Of Cardiac Surgery Patients To The Intensive Care Unit (ICU) 1646 -‐ Combining Professional Advancement And Patient Safety: Developing A Novel Professional Certification Program For Nursing Technicians In Brazil 1659 -‐ Geographic Variations In Rate Of Failure-‐To-‐Rescue Among Surgical Patients: A Population-‐Based Study In New South Wales, Australia 1710 -‐ Invite Caregiver Prevention Falls Reduces Incidence Of Psychiatric Patient Falls At The Medical Center In Taiwan 1733 -‐ Development And Validation Of A Hospital Safety Attitude Questionnaire In Korean And The Application Of The Empirical Bayes Method 1755 -‐ A Maximum Difference Scaling Survey Of Barriers To Intensive Combination Treatment Strategies In Early Rheumatoid Arthritis 1765 To Achieve 100% Discharge Of *Appropriate Elective* As 23 Orthopaedic Patients Before 1,000Hrs Within 6 Months 1799 -‐ Involving The Family In The Adherence To Hand Hygiene (HH): A Multi-‐Disciplinary Study With Playful Strategies 1806 -‐ Implementing An Electronic Medication Overview In Belgium 1833 – Re-‐admission Rates As A Quality Indicator: A Systematic Review Of Methodological Conditions And Scientific Evidence On Validity 1866 -‐ Improvement Of Surgery Preparation Process And Indication Of Correct Surgery Site Of Orthopaedic Surgery Patient To Prevent Wrong Site Surgery 1875 -‐ Risk Evaluation Of Errors Arising From Patients Identification In An Obstetric Unit Of A Teaching 1878 -‐ Operational Safety Program Based On Human Factors Approach: The Proposal Of A Model For Critical Care Units 1893 -‐ Minimising The Waiting Time During Discharge To Achieve More Effective Use Of Patient Beds 1903 Improvement Of The Exacerbation Of Patients With COPD By Identifying And Correcting The Technique Of 1914 -‐ Clinical Laboratory Job Safety/Hazard Analysis Regarding Charcoal Mask Usage In Collection Points For Formaldehyde 1925 -‐ How Do Individual And Organisational Factors Impact The Relationship Between Clinician Burnout And Patient Safety? 1964 -‐ What Can We Learn From A Decade Of Patient Safety Incident Reports? A Quantitative Analysis Of The National Reporting And Learning System Data 1977 -‐ Implementation Of A New Change-‐Of-‐Shift Report Model For Improvement Of Handoff Communications 2012 -‐ Evaluation Of Implementing A Standardised Innovative Rapid Response System In Australian Hospitals 2035 -‐ Using A Computerised Barcode System For Surgical Instrument Packs To Enhance Instrument Management 2037 -‐ Improving Safety And Quality Of Mental Health Care Units In South Brazil 2065 -‐ Paediatric Clinical Practice Guidelines Audit Project 2080 -‐ Using Control Charts To Monitor And Assess Improvement Of Catheter-‐Related Bloodstream Infection In Surgical Intensive Care Unit 2081 -‐ The Improvement Of Patient Safety By Water Aerators Maintenance 2083 -‐ Enhancing Patient, Staff And Equipment Safety Through Failure Modes And Effects Analysis (FMEA) On MRI Suite Safety In JCI Accredited Tertiary Care Teaching Hospital 2086 -‐ A Case Study Of The Investment Cost For Patient And Healthcare Workers Safety Concerning PCI 2087 -‐ Applying Innovative Cloud Technology For Ureteral Stent Implants Management 2095 -‐ Adverse Events And Death Related To The Use Of The Magnetic Resonance Equipment 2120 -‐ Quality And Patient Safety Tuesdays: Transforming An Auditing Process Into A Continuous Improvement 2141 -‐ Development And Validation Of An Alert Mechanism That Precedes Expected Bed Exit In Hospitalised Patients 2149 -‐ Reducing The Irrational Use Of Therapeutic Antibiotic In Elective Caesarean Section 2192 -‐ An Evaluation Of A Complex Social Intervention To Build High Reliability Patient Care Teams 2193 -‐ Developments Of Culture Of Patient Safety: Comparative And Linear Analysis With Americans Hospitals 2195 -‐ Introduction To Prospective Analysis Of Patient Safety By Risk Audits 2217 -‐ Use Of Team Resource Management Technique To Improve Extra-‐Corporeal Membrane Oxygenation Care Quality 2222 -‐ Global Trigger Tool: An Approach To Enhance Patients’ Safety 2230 -‐ Governing Correct Surgical Count Through ViGO (Visual Gauze Organiser) 2286 -‐ Reducing Hazards Through Handover: A Central London Teaching Hospital Experience 2327 -‐ A Simple Solution To The Problems Encountered During Junior Doctor Change-‐Overs In The NHS, UK 2333 -‐ Consensus Of Items And Quantities Of Clinical Equipment Required To Deal With A Mass Casualties Big Bang Incident: A National Delphi Study 2345 -‐ Critical Missed Doses: Education And Audit Package 2352 -‐ Development Of An Incentive Program, Focused On Adverse Events Prevention And Strengthening Of Patient Safety In México 2384 -‐ Team Resource Management Improves Safety Of Transfer Of Post-‐Surgical Critical Patients To Intensive Care Units 2385 -‐ The Ins And Outs Of Paediatric CVAD's 2425 -‐ Transforming Health: Creating A Culture Of Quality Improvement 2432 -‐ How Visual Management For Continuous Improvement Might Guide And Affect Hospital Staff – A Case Study 2468 -‐ What Do Hospitals In São Paulo State Do Regarding Safety Issues: An Intended Census 2480 -‐ Risk Management Assessment As A Means Of Fostering Safety In Healthcare 2498 -‐ Bedside Care Teams: Disseminating The Concepts Of Patient Safety 2502 -‐ Identification And Classification Of An Adverse Event Using An Adapted Who International Classification For Patient Safety (ICPS) Taxonomy 2521 -‐ Assessment Of The Surgical Safety Checklist: A Before And After Study Design 2528 -‐ Computerisation Of The Diet Census At Hospital Estadual Sumaré 2538 -‐ Automated Methods Of Adverse Events Detection: A Critical Review Of The Literature 2551 -‐ Implementation Of A Plan Of Care In Situations Overcrowding In A Unit Of Emergency 2554 -‐ Safety Administration Of Contrast: Imaging State Hospital Sumaré 2571 -‐ Awareness Towards Falls Prevention To Reduce Patients’ Harm: A Report Of Nurse Staff Compare With Three Academic Affiliated Hospitals In North Taiwan 1102 -‐ Central-‐Line Associated Bloodstream Infections In Private Intensive Care Units In Brazil 1456 -‐ Process Mapping And Risks: An Experience Report About The Implementation In The Management Of Hospital 9 De Julho 1603 -‐ Evaluating The Quality And Safety Of Perinatal Care Using Administrative Data: A Systematic Review And Retrospective Cohort Study 1658 -‐ The Practice Of Epidural Anaesthesia In Princess Marina Hospital Labour Ward In Botswana: A Clinical Outcome Audit 1950 -‐ Using Intern Audit To Verify Safety Practices In The Use Of Concentrated Electrolytes 1960 -‐ Use Of Fall Profile And Incidence To Reassess The Current Prevention Practice Of A Paediatric Hospital In Brazil 1976 Empowerment Of Middle Management In Improving And Analysis Of Institutional Protocols At Hospital UniMed Santa Helena 2174 -‐ Prioritise: Asking Healthcare Professionals About Patient Safety Priorities In Primary Care 2343 -‐ Surveillance Of Multi-‐Resistant Bacteria (MRB) At Principal Hospital Of Dakar: Assessment Of 1 Year 2558 -‐ The Impact Of The Nursing Records’ Standardisation Over The Loss Of Financial Income Related To Dressing Material 2582 -‐ Leading Practice In Venous Thromboembolism Prophylaxis 2585 -‐ Creating A Database For Prevention Of Nosocomial Infection In A Federal Hospital At The City Of Rio De Janeiro 2592 -‐ How To Involve The Professional Tip To Follow Mandatory Safety Practices (ROP): A Successful Report Experience In A Health Care Institution 2188 -‐ Correlation Between The Annotation Nursing X Rates Of Nursing Services And Use Of Additional Equipment On Private Hospital Services 2579 -‐ Using Trigger Tool To Identify Adverse Drug Events In Cardiology Hospital 1062 -‐ The Satisfaction Of Newly Admitted Patients Towards Their Ward Environment 1082 -‐ A Nursing Experience For The Oesophageal Cancer Patient Caring By Orem Theory 1485 -‐ A Nurse’s Personal Experience In The Care Of A Chronic Obstructive Pulmonary Disease Patient 1687 -‐ Spotlight On Nutrition – A ‘Must’ For Assessment 1771 -‐ Daily Goals In Multidisciplinary Care For Patients With Acute Myocardial Infarction (AMI) 1851 -‐ The Impacts Of Outpatient Integrated Care On Quality Indicators Of Diabetes Patients With Chronic Diseases 1969 -‐ Elder Patient Clinical Management Hospitalised With INTERMED Methodology 2079 -‐ A Protocol To Investigate How Clinicians And Patients Define Roles And Interact In A Multi-‐ Disciplinary Ward Round 2355 -‐ Integrated Care: The Effectiveness Of Pain Management Education For Patients Undergoing Cardiac Surgery 2417 -‐ Bariatric Surgeries In Patients With Diabetes Mellitus -‐ Do They Enhance Reaching The Clinical Quality Indicators Goals? 2418 -‐ Facilitating Improvement In Medical Record Documentation For Inpatient Consultations 1874 -‐ Health Record In Emergency Units: Management Tool For Integrated Health 2440 -‐ Palliative Care In Romania Developments, Legislation And Questions 2198 -‐ Leveraging Knowledge Management Techniques To Improve Improvement Programs In Low And Middle Income Countries 2328 -‐ Strengths, Weaknesses, Opportunities And Threats (SWOT) Analysis To Highlight The Areas Of Concerns And Challenges Faced By Today’s Allied Health Science Professionals 2489 -‐ The Challenges For Implementing The Lean Six Sigma Methodology In A Brazilian Oncology Centre 1493 -‐ Inequalities In Female Breast Cancer Survival: A Study Using The Population-‐Based Cancer Registry Of São Paulo, Brazil 2112 -‐ Quality Of Pressure Ulcer Care In Indonesian Hospitals: Prevalence, Prevention, Treatment And Structural Quality 2153 -‐ Ways Of Communicating An Innovation 1047 -‐ Reducing The Incidence Of Pressure Sores Induced By Skin Pressure Caused By Oxygen Tubes 1058 -‐ Nursing Experience For A Patient With A Spinal Cord Injury Caused By Car Accident 1084 -‐ Developing A Patient-‐Led Incident Reporting Scheme For Renal Patients 1178 -‐ A Brief Instrument Effectiveness In The Assessment Of Dissatisfaction Of Health Care Centers Users Avoiding “Ceiling Effect” 1185 -‐ Reducing Treatment Default And Improving Patients’ Healthcare Experience By Minimising Stock Out Situation At The Specialist Outpatient Clinic Pharmacy 1194 Personal Context And Childhood Experiences Affect Adult Vaccination Behaviour 1243 -‐ Improvement Of Effective Shift Handoff Process By Using ISBAR Techniques 1248 -‐ Interventions To Promote Psychiatric Patients’ Compliance To Mental Health Treatment: A Systematic Review 1308 -‐ Delivering Timely Specialist Care To Subsidised Inpatients In A Tertiary Hospital 1328 -‐ Applying “J” Saliva Ejectors With Creative Design To Reduce The Cost In Home Care 1361 -‐ The Efficacy Of Dysphagia Nursing Interventions For Aspiration Pneumonia In Oesophageal Cancer Patient 1367 -‐ The Failure Mode And Effect Analysis (FEMEA) For A Chemotherapy Center Of UniMed Campinas (CQA) 1428 -‐ Streamlining Reporting System Of Critical Neonatal Bilirubin Results Through A Quality Project 1491 -‐ Chronic Related Groups In Lombardia Region Strategy: Continuum Of Care And Value For Patients 1506 -‐ Risk Management In The Discharge Of The Cath Lab 1509 -‐ The Impact Of The Implementation Of A Quality Programme In Anaesthesiology At A Reference Hospital In The State Of São Paulo 1514 -‐ Brazilian Experience In Family Involvement Concerning The Internality Of The Care Of Patients With Acute Stroke According To Canadian Distinction Stroke Program 1558 -‐ Integration Of Evidence-‐Based Practice And Patient-‐Centered Care By Clinical Practice Guidelines; The Current Status In Japan 1563 -‐ A Clinical Practice Improvement Programme (CPIP) On Right Siting Of Patients From An Asthma Clinic To The Primary Care Team Within 6 Months 1571 -‐ Using A Diabetes Bundle To Measure The Quality Of Care In The National Healthcare Group, Singapore 1590 -‐Improving Compliance Of Prophylactic Antibiotic Administration In Obstetrics & Gynaecology, Through Empowerment Of Operating Room Nurse 1592 -‐ Patient-‐Doctor Communication In Primary Care – Patients’ Values And Experiences 1602 -‐ Implementation Of Radiology Electronic Order Entry System At Emergency Department (ED) To Enhance Patients’ Safety And Efficiency In A Tertiary Care Teaching Hospital 1624 -‐ The Controversial Usefulness Of Patient Experience Measures: Contribution Of Literature Analysis Applied To Myocardial Infarction (MI) 1631 -‐ Assessment On The Impact Of Implementing A VAP Prevention Protocol On The Incidence Density Of Infection 1746 -‐ Enhancement Of The Effectiveness Of Nutrition Care For Head And Neck Cancer Patients 1778 -‐ Developing A Surgical Rapid Response Team 1788 -‐ Team Resource Management In Medical Intensive Care Unit (MICU) To Reduce Unplanned Extubation (UE) Incidents 1807 -‐ The Association Between LDL Levels And CVD Within The Community: An Observational Study 1819 -‐ Reduction In Orotracheal Intubation Time, Increase In Rates Of ICU Discharge On Day 1 Postoperative (PO) And Hospital Discharge On Day 4 PO In Myocardial Revascularisation 1879 -‐ Relationship Between Patients’ Perceptions Of Care Quality And Patient Safety In 11 Countries: A Secondary Data Analysis 1939 -‐ Use Of Dextrose 25% As A Trigger Tool To Identify Hypoglycaemia Related Adverse Drug Reactions From 1948 -‐ "Saving Lives": Communicating Radiological Panic Results To The Right Person At The Right Time [Panic Alert] 1961 -‐ Planetree Designation -‐ A Quality Model For Increasing Patient Satisfaction In A General And Private Hospital 2006 -‐ Assessing Patient Cognition And Behaviour In Specialised ALS Multidisciplinary Care: A Feasibility Study To Improve Patient-‐Centred Care 2010 -‐ Reducing Surgical Site Infection Rate In Caesarean Cases Through A Quality Project At The Aga Khan Hospital For Women, Garden-‐ Pakistan 2027 -‐ The Quality Of Patients’ Records Evaluated By Indicators 2034 -‐ Use Of Lean Thinking To Decrease The Time Of Drug Administration In Patients Admitted To A Unit Of Bone Marrow Transplantation 2092 -‐ Project: Pain Reduction In Intubated Patients 2134 -‐ A Medical Centre Emergency Environmental Noise Improvement Project 2138 -‐ Improving Clients Satisfaction Through The Client-‐Customised Waiting Time Management During Medical Consultation 2202 -‐ Systematic Application Of The Safe Surgery Checklist As An Effective Tool To Reduce Adverse Events In Surgical Interventions 2229 -‐ National Healthcare Consumer Experience Survey, State Of Qatar 2238 -‐ Facilitate Patients In Early Diagnosis Of Breast Cancer Through Post-‐Mammography Breast Ultrasound Procedures 2249 -‐ Adherence And Understanding Of The Multidisciplinary Educational Process Of Patients Undergoing Total Hip Replacement In The Hospital Alemão Oswaldo Cruz And Their Profile 2275 -‐ Different Patterns Of Laboratory Procedures In Patients Undergoing Hernia Repair – Results Of An Eight Hospital Study 2287 -‐ Survey And Implementation Improvements In Pain Management Of A Private Institution In The City Of São Paulo, Brazil. 2288 -‐ Review And Revise Patient Satisfaction Survey Questionnaire Using HCAHPS Guidelines And Conducting Market Research Study To Identify Patients’ Preferences 2299 -‐ An Initiative Towards Eliminating Patient’s Visit To Collect Report And Films At A Radiology Facility -‐ A Simple Out-‐Of-‐The-‐Box Approach Towards Patient Centeredness 2329 -‐ Do We Need Radiology Recovery Room? Assessing The Efficient And Effective Utilisation Of Radiology Recovery Room (RR) At JCI Accredited Tertiary Care Teaching Hospital. 2411 -‐ Developing A System For Electronic Data Collection Of Patient Satisfaction And Experiences In Norway 2445 -‐ Forgotten? –Dementia Care In Acute Hospitals In The UK 2453 -‐ Patient Transport From Wards To The Operating Theatre By Wheelchair 2479 -‐ Screening Indicators At Emergency In A Private Hospital In São Paulo 2485 -‐ So You Want To Create A Culture Of Service Excellence? What It Takes? Story Of A Journey From 2011 To 2013: Interventions, Challenges And Recommendations 2507 -‐ Disease Management Program In Maintaining Patient Satisfaction 2543 -‐ Comparison Of Nutritional Status Of Cancer Patients In A Private Hospital In São Paulo 2566 -‐ Urinary Tract Infection Related To Use Of A Urinary Catheter In Intensive Care Unit Of Hospital Estadual Sumaré, São Paulo, Brazil 2594 -‐ Impact Of The Implementation Of Unit Dose Of Oral Liquid Medications For Paediatric Patients In A Large Philanthropic Hospital 2586 -‐ The Vulnerability Of Cancer Patients And Palliative Care As A Protective System 1503 -‐ Effects Of A Pain Education Program On Pain Management Practices In Hospitalised Patients 1938 -‐ Surgical Patient Care Risk Analysis 2029 -‐ IPSG 2 – Effective Communication Handover/Handoff – Importance Of Communication In Shift Changes Of Nursing 2578 -‐ Experience Report: Managing Protocol Delirium In Intensive Care Units (ICU) 2584 -‐ Impact Of A Program Of Functional Rehabilitation And Early Ambulation To Prevent Immobility As Part Of A Venous Thromboembolism Prophylaxis Protocol In Hospitalised Patients. 2590 -‐ The Impact Of Nursing Activities In Chest Pain Protocol: Optimising Time Door-‐To-‐ ECG 2365 - Fight For The Moment-Emergency Care For Postpartum Haemorrhage 1145 Quality Improvement Through International Accreditation Programme In Indonesia Dewi Indriani* 1, Yohanes Baptista Ari Handoko2, Mohammad Shahjahan1, Martin W. Weber3 1 Health System Strengthening, 2Child and adolescent health, WHO Indonesia Country Office, Jakarta, Indonesia, 3Making Pregnancy Safer and Reproductive Health, WHO Regional Office for South-‐East Asia, New Delhi, India Objectives: Indonesia continuously makes efforts to improve quality of health services in the country. Every year, a significant number of Indonesians go abroad seeking better quality of health care. In response to this problem, the Government of Indonesia made efforts to improve the quality of health care in the country. One of the initiatives is by joining an international hospital accreditation program to gain a better reputation as a world class hospital. A series of activities have been conducted to improve the readiness of these hospitals to undergo the JCI accreditation survey, such as a gap analysis, monitoring and evaluation, collaborative meetings and a JCI mock survey. The study aims to analyse the strategies which were implemented by the hospitals to improve their readiness for the JCI initial accreditation survey and view the strengths and weaknesses of the strategy. Methods: The results of baseline assessment, gap analysis, monitoring evaluation and mock survey findings were scored “0-‐5-‐10”. Then comparative analysis was made to see the trends in data. Results: Despite all assessment referred to the same standard, the results of each assessment was inconsistent and not reflecting continuous improvement from initial assessment up to mock survey. For instance, in improving the safety of high alert medications standard, it’s scored “10” in gap analysis and monitoring evaluation and got “0” for the mock survey. The inconsistencies are most likely as each assessment conducted by different assessor and using different tools, therefore impact of the process in improving readiness was not clear. Conclusion: The strategy implemented may help hospitals in improving the readiness for the initial accreditation survey as each process provided recommendations for improvement, however all assessment should be synchronised to view the clear impact. References: Joint Commission International, Accreditation Standard for Hospitals 4th Edition, JCI, Illinois, 2011 1224 How Can We Take Into Account Effort, Excellence And Uncertainty When Rewarding Quality In Hospitals: A French Initiative Of P4P Program Shu Jiang* 1, Melanie Couralet2, Sylvain Baillot3, Etienne Minvielle1 1 COMPAQ, Villejuif, 2HAS, Saint Denis, 3Ministry of Health DGOS, Paris, France Objectives: Pay-‐for-‐Performance (P4P) programs have recently been developed worldwide, such as VBP of U.S. Medicare & Medicaid Services. In July 2012, the first hospital P4P program launched by the French government, IFAQ, was announced to all the 1350 French acute care hospitals. The objective of this study was to develop a scoring method, based on the principle to take into account excellence, effort and uncertainty in quality measurements used for IFAQ. Methods: The design of IFAQ, proposed by the research team COMPAQ, was validated by a working group (WG) including representatives of French Ministry of Health (DGOS), French National Authority for Health (HAS) and hospitals federations. French hospitals are required to submit a number of quality assessments: a 4-‐year cycle of accreditation based on 85 standards, among which 19 are priority standards (PS), and a yearly collection of quality indicators (QI), mostly based on evaluation of random samples of medical records. The QI class result depends on its position of upper and lower confidence interval limits compared to a national benchmark. Accreditation decisions and QI results are made public. Six principles were adopted: 1) hospitals' data collection burden should not be increased, by using only publicly available quality measurements; 2) QI measurement uncertainty should be taken into account; 3) hospitals’ quality level (excellence) and efforts for improvement should be appraised; 4) hospitals could apply only if accreditation decisions did not include reservations; 5) quality should be measured before experiment launching and a year after; 6) incentives should only be positive. An experimental group of 222 hospitals was randomly selected from 450 candidates, representing major hospital categories according to size, status (profit, non-‐profit), ownership (public, private) and university affiliation. Results: The WG selected 16 components of quality measurements: 7 mandatory QIs, surveyors’ assessment of 8 accreditation PS, and an assessment of hospitals involvement in producing Electronic Medical Records (EMR). Class result of each QI is adopted (A [best], B or C [worst]); PS assessment reflects absence or number of recommendations, hospitals involvement in EMR depends on fulfilment of national requisites and on computerisation of medical records. A component score for each hospital and each component is obtained by summing up achievement at year 2014, giving 10 points to a class A result, 5 to class B and 0 to class C, and effort measured by adding/subtracting 3.5 or 7 points if results vary by one or two classes, respectively, compared to 2012. A bonus/penalty of 10 points is given when a component remains in the best/worst class. The final component score is transformed to a scale from 0 to 10 (Table 1). Year 2012→2014 A→A A→B A→C B→A B→B B→C C→A C→B C→C Excellence (achievement) 10 5 0 10 5 0 10 5 0 Effort (± bonus/penalty) 0 (+ 10) -‐3.5 -‐7 3.5 0 3.5 7 3.5 0 (-‐ 10) Sum (-‐10 to +20) 20 1.5 -‐7 13.5 5 -‐3.5 17 8.5 -‐10 Component Score (0 to 10) 10 3.8 1 7.8 5 2.2 9 6.2 0 The WG decided on the weight of each component. Results of component scores for each hospital are aggregated, based on these weights, into a quality composite score. Conclusion: Financial incentives (0.3 to 0.5% of global budget) are to be given to hospitals ranking in the top 30% of quality composite score distribution. At the end of 2014, the impact of IFAQ will be evaluated by comparing composite score results of the experimental group (222 participants) to those of non-‐participants, using a difference-‐in-‐difference method combined with propensity score matching. 1229 Validation Of An Indicator Assessment Tool For Accreditation: Identifying Hand Hygiene Compliance Rates As A Process Indicator Virginia Mumford1, David Greenfield* 1, Anne Hogden1, Jeffrey Braithwaite1 1 Australian Institute of Health Innovation, UNSW, Sydney, Australia Objectives: Hospital accreditation programs are internationally widespread and consume increasingly scarce health resources. However we lack the tools to consistently identify the benefits of accreditation in order to monitor and compare accreditation outcomes. We describe the validation of a purpose designed indicator assessment tool.1 Methods: We used our indicator assessment tool to make a preliminary selection of potential accreditation indicators by analysing the Australian hospital accreditation standards. For each standard we: reviewed the research evidence; looked for links with existing external indicators; reviewed relevant state and federal policies; and checked the accreditation standards contained consistently relevant content for retrospectively comparing indicators with accreditation outcomes. Using a five point Likert scale, we allocated provisional scores to the five accountability criteria in the tool: research; accuracy; proximity; no adverse effects; and specificity. We then convened an expert panel to assess the tool, using a key indicator to demonstrate the selection process. The panel comprised seven Australian based researchers working on health services accreditation and three international healthcare quality and safety experts. Panel members were presented with a description of the tool, indicative scores and rationale for those scores, and research evidence for the selected indicators. We used an evidence-‐based consensus approach to synthesise the panel findings. Results: Our expert panel validated the use of our indicator assessment tool in identifying accreditation indicators and determined that hand hygiene would likely be a suitable process indicator. This was predicated on allocating high scores for the research evidence for implementing a multimodal program as recommended by the World Health Organisation, and the organisational and temporal proximity between accreditation surveys and hand hygiene audits. The risk of adverse events was allocated a medium score as the data are self-‐audited against known targets. Accuracy was given a medium to low score as the infection control standard includes a broad range of anti-‐microbial and specialist cleaning policies which would not be measured by this indicator. Specificity was scored low due to a number of related policy programmes, making it difficult to isolate the effects of accreditation. Conclusion: Using hand hygiene audits as a process indicator for accreditation has merit in terms of the research evidence and a clear link to the organisational processes required to meet the infection control criteria. However this may be offset by the lower scores for specificity and accuracy in the indicator assessment. A comparison of accreditation and hand hygiene outcomes is needed to assess the efficacy of the indicator. Validation of a purpose designed tool for identifying, analysing and comparing accreditation indicators provides health policy makers with an important means for assessing a critical part of the patient safety and quality framework. Testing is needed across the acute and aged care health domains to confirm robustness across the health services sector, both domestically and internationally. References: 1. Mumford V, Greenfield D, Hinchcliff R, et al. Economic evaluation of Australian acute care accreditation (ACCREDIT-‐ CBA (Acute)): study protocol for a mixed-‐method research project. BMJ Open 2013;3(2). 1255 Applicability Of Tools Used By The Hospital Manager Aurea V. Pereira Pinheiro* 1 1 Bioxxi, Rio De Janeiro, Brazil Objectives: This paper aims to show what are the tools used in day to day of a hospital manager and discuss the main tools of quality. The method used was a literature review in VHL (Virtual Health Library), based on data LILACS, BDENF, SciELO, as well as books and academic research in google. In the filter search were searched articles, dissertations and monographs. The keywords used were: quality, total quality and nursing. Found 2,244 jobs, it was necessary to refine the search, 06 studies were found. We conducted a descriptive study, in the form of a systematic review of the literature found in the last 10 years. The core of the discussion reveals the need to know the professional tools you need to manage a hospital. Thus, we observed a number of incident research that address the issue. Methods: Descriptive study was conducted in the form of a systematic review of the literature found in the last 10 years. The core of the discussion reveals the need to meet the professional tools necessary to manage a hospital. Results: The limitations encountered in conducting the study are: the reduced quantity of scientific material encompassing issues related to the topic. It is clear, thus, the need for further studies by students and related professional area. Conclusion: Today the Brazilian scenario is shown as a reference in several countries such as hospital management model. Health institutions being private or public need to apply more and more quality tools and indicators that include the information necessary for the manager to manage effectively their institution manner. References: Lakatos. Paulina Kurcant 1282 Introducing And Promoting Community-‐Based Mental Healthcare Model Through Accreditation Li-‐Yun Wen1, C.F. Chiang1, Pei-‐Yu Chen1, Hung-‐Jung Lin* 2 1 Devision of Hospital Accreditation, 2Chief Executive Officer, Taiwan Joint Commission on Hospital Accreditation, New Taipei City, Taiwan Objectives: Statistical data published by the Department of Health(DOH), Executive Yuan in 2011 showed that 123,572 cases were registered on file as mentally disabled(due to organisation re-‐structuring on July 23rd, 2013, the DOH will henceforth be referred to as the Ministry of Health and Welfare(MOHW). To assist the chronic mental disabled patients, who may have suffered multiple disabilities due to increasing old age and have decreased living functions, to return to community life and improve their quality of life, the government sought to promote a community-‐based mental healthcare model. It has implemented an accreditation mechanism to regularly review and confirm the service qualities of psychiatric rehabilitation institution and psychiatric nursing home. Methods: In order to comply with current national health policies, Taiwan Joint Commission on Hospital Accreditation (TJCHA) collected literatures on community-‐based mental rehabilitation institutions, and performed analysis on the items and results of the 2010~2011 accreditation standards. There are 20% community related clauses; half-‐way house accreditation was 25% community related clauses. We revised the following principles based on the 2011 meeting of consensus of the committee on psychiatric rehabilitation institution, recommendations from the institutions themselves, and policies of central competent agency: Integration and simplification of standard items, direct institutions to community development, and enhance self-‐ empowerment of students/residents and environment safety. On the other hand, to improve the functions of the psychiatric nursing homes and enhance the operational standards, the TJCHA also set up a task force, opinion feedbacks from psychiatric nursing homes. To devise principles of revision: Simplifying the standard items, for necessary item such as personnel, facility equipment and management, the scoring should be Met/ Not Met. Results: The revised standards on Psychiatric Rehabilitation Institution Accreditation included six chapters on human resource management, space and facility, provision of rehabilitation services, management of rehabilitation services, integration of community resources, and the recommendations of improvement from previous evaluation; the overall community clauses increased 15%.The revised standards on accreditation of psychiatric nursing homes remained six chapters, focusing on aging of chronic mentally disabled patients and integrity of long-‐term care. Aside from the integration of public health and social policies, the key area of improvement are capacity building of professional personnel. Conclusion: The national mental healthcare policies should integrate resources and expand on the healthcare subsidies to the psychiatric patients, through combination of accreditation and the project of psychiatric healthcare network. The strategies may include establishing administrative organisation to govern mental healthcare, building or expanding on mental healthcare facilities, improving primary mental healthcare, promotion of rehabilitation homes, community rehabilitation centers, household treatment and risk management. References: 1. Anthony, W.A.,& Farkas, M.D.(2009).Primer on the psychiatric rehabilitation process., Boston University Center for Psychiatric 2. Joint Commission International Accreditation（2012）, Joint Commission International Accreditation for Long term care 1st, http://store.jointcommissioninternational.org/jci-‐accreditation-‐long-‐term-‐care-‐survey-‐process-‐guide-‐pdf-‐book-‐/ 3. Kilbourne, A.M., Keyser, D., Pincus, H.A.(2010)., Challenges and Opportunities in Measuring the Quality of Mental Health Care., The Canadian Journal of Psychiatry,55(9),549-‐557 1299 Evaluation Of Health Services: The Roadmap Of PNASS Applied In Surgical Centre Paloma A. Carvalho* 1, Leila B. D. Gottems2 1 Office of Quality and Security, Hospital de Base of the Federal District, 2Postgraduate Program in Sciences for Health, Superior School of Health Sciences, Secretary of Health of the Federal District, Brasília, Brazil Objectives: To evaluate the surgical center of a public hospital of high complexity with the instrument of the Programa Nacional de Avaliação de Serviços de Saúde (PNASS – in English, National Health Services Evaluation Program). Methods: The Roadmap of Conformity Standards of the Programa Nacional de Avaliação de Serviços de Saúde (PNASS – in English, National Health Services Evaluation Program) was used, and it contains twenty-‐two criteria divided in three blocks: Organisational Management, Technical and Logistics Support, and Management of Health Care. Patterns of conformity sentinels, classified as Indispensable (I), Necessary (N) and Recommended (R), were defined and they are items that signal risk or compromise the quality. In each criterion, there are two items for each classification, totalling six items per criterion. The patterns classified as Indispensable are required in standards, and non-‐compliance of them involves immediate risks to health. Patterns classified as Necessary, also required in standards, entails mediate risks when the non-‐compliance occurs. The Recommended patterns are not described in standards and determine a differential of quality in service provision. For attestation of each item, one or more verification technique, indicated in the roadmap, was employed, and it can be the Observation (O), analysis of Documentation (D) or analysis of records (P). Having proof of compliance with the checked item, it was assigned a positive or negative marking. Each criterion of the Roadmap has a maximum score of 12 points and assigned percentage of 100%. The maximum score is related to the number of criteria that have been verified according to the type of care of the health establishment, in this case 15 criteria were evaluated. Results: The average of evaluation criteria was of 51.66 % of conformity, which ranged from low percentages, such as criteria User Demand and Society, Food and Nutrition which obtained both 16.65% of conformity, until more appropriate percentage, as in criteria Leadership and Organisation and Haematology Services, which reached 83.3 % of conformity. The criterion Surgical and Anaesthetic Care achieved 58.3 % of conformity, a relatively low percentage, especially when analysing the context of the evaluated service in a public hospital of high complexity. The criteria Management of Physical Infrastructure (41.65%), Management of Equipment (25%) and Management of Materials (25%) also obtained percentages well below of the expected and recommended. The Management of Information obtained 75% of conformity, and other criteria (People Management, Risk Management, Environment Safety and Clothing Processing, Auxiliary Services of Diagnosis and Therapy, Humanisation of Assistance, Immediate Attention to Urgency and Emergency) fluctuated between 41.7% and 66,65 %, all below of the 80% recommended to ensure minimum standards of quality and safety in patient care. Conclusion: Evaluation in health presupposes the efficiency, effectiveness and the effectiveness of the structures, processes and results related to risk, to access and satisfaction of users of health services. The evaluation of a highly complex service, such as the setting of this study, is essential for managers to plan their actions, because it allows identifying which aspects of the system need greater efforts, as well as which aspects that may increase the risks during the healthcare process, and with this reorder the execution of actions and services, resizing them so as to cover the needs of the users and optimise the use of resources. 1462 A Study Of Large Hospitals' HSMR (Hospital Standardised Mortality Ratio) In Korea Min Sun Shin* 1, Eun Kyong Ko1, Chuel Un Park1, In Sook Shin1 1 Quality Assessment Developing, Health Insurance Review And Assessment Service, Seoul, Korea, Republic Of Objectives: The in-‐hospital mortality is one of the important essential quality measures. The aim of this study is to compare the pattern of HSMR (Hospital Standardised Mortality Ratio) of admitted patients in large hospitals (tertiary hospitals and general hospitals with over 500 beds). Methods: 1. Data source: The data (N=2,531,693) used in this study is 2012 inpatient claims data submitted to HIRA (Health Insurance Review & Assessment Service) from 91 hospitals (44 tertiary hospitals and 47 general hospitals with over 500 beds). The 259 conditions were grouped by ICD (International Statistical classification of Disease) -‐10 code using AHRQ (Agency for Healthcare research and Quality) CCS (Clinic Classification Software). We excluded transferred admission, emergency admission with in a day and palliative care. 2. Observed deaths: The observed deaths is defined as hospital in a death. To obtain accurate date of death, we used death date data linked with MOSPA (Ministry of Security and Public Administration). We use the 37 diagnostic groups which contribute to 80% of in-‐hospital deaths, and selected final data of 761,097 of admissions. 3. Expected deaths: The variables were sex, age, type of health insurance, operation, emergency admission, diagnosis code, elix hauser comorbidity index. For each diagnosis group, we derived predicted probabilities for inpatient in-‐ hospital mortality by fitting logistic regression model in which backwards elimination procedure for comorbidity variable selection. Each model was evaluated using c-‐statistics and goodness-‐fit test. 4. (4) Classification of HSMR: The HSMR was calculated as the ratio of observed deaths to expected deaths by hospital, multiplied by 100 and national average was 100. With the standard of CI (confidence interval) being 99.8%, hospitals with lower CI greater than the average (100) were classified as 'insufficient', hospitals with CI that include the average as 'no difference', and hospitals with upper CI smaller than the average as 'good'. Results: Among 44 tertiary hospitals, 9 were good, 12 were insufficient, and 23 were no difference. Among 47 general hospitals with over 500 beds, 8 were good, 10 were insufficient, and 29 were no difference. Insufficient hospitals portion of tertiary hospitals was more than general hospitals over 500 beds. HSMR status Total Tertiary hospitals General hospitals with over 500 beds Total 91(100.0%) 44(100.0%) 47(100.0%) Good 17(18.7%) 9(20.4%) 8(17.0%) No difference 57(62.6%) 23(52.3%) 29(61.7%) Insufficient 17(18.7%) 12(27.3%) 10(21.3%) Conclusion: We identified the difference of quality of care among hospitals by calculating HSMR CI. Thus, HSMR is able to use a quality indicator which compare between a hospital and national average. 1486 Accreditation And Improvement In Process Quality: A Nationwide Study Søren B. Bogh* 1, Erik Hollnagel1, Søren P. Johnsen2, Anne Mette Falstie-‐Jensen2 1 Centre for Quality, Region of Southern Denmark, Middelfart, 2Department of clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark Objectives: To examine the development in process quality related to stroke, heart failure and ulcer (bleeding and perforated) between accredited and non-‐accredited hospitals. Methods: All Danish hospitals which treated patients with stroke or heart failure during 2004-‐2008 or treated patients with bleeding or perforated ulcer during 2006-‐2008 were included. The hospitals were categorised in two groups, non-‐ accredited hospitals (i.e., hospitals not participating in an accreditation program) and hospitals accredited either by Joint Commission International or Health Quality Service. Individual-‐level processes of care data was obtained from national population-‐based registries. The accredited and non-‐accredited hospitals were compared using 19 processes of care indicators reflecting hospital compliance with national clinical guidelines. The 19 indicators included seven indicators for stroke, seven indicators for heart failure, three indicators for bleeding ulcer and three indicators for perforated ulcer. The primary outcome was the composite fulfilment of process indicators. The secondary outcome was all-‐or-‐none, defined as the proportion of patients receiving 100 % of the recommended processes of care. Two-‐sided t tests were used for statistical analysis with p < 0.05 as a significance level. Results: A total of 70120 patients from 24 hospitals were included. Analysis of the composite fulfilment of process indicators showed no differences at baseline between accredited and non-‐accredited hospitals for neither stroke (P = 0.55), heart failure (P=0.88), bleeding ulcer (P=0.67) and perforated ulcer (P =0.16). Non-‐accredited hospitals performed better in the study period regarding stroke (P<0.01), whereas no clear differences were found for heart failure, bleeding ulcer or perforated ulcer. Non-‐accredited hospitals had statically larger improvement in all-‐or-‐none indicator related to stroke compared with accredited hospitals (P = 0.04). No difference in heart failure, bleeding ulcer or perforated ulcer was found. Conclusion: This study does not support the hypothesis that accredited hospitals provide better process of care quality. 1498 Adequacy Of Health Services Of A Private Health Plan: How Accreditation Can Contribute -‐ An Innovation In Brazil 1 * 2 3 Sylvia R. Cozer , José D. L. Valverde Filho , Mercêdes M. Beringer 1 2 3 IBM, Consorcio Brasileiro de Acreditação, Cesgranrio, Rio de Janeiro, Brazil Objectives: Consumer’s complaints against “Health Plans " are in top lists of institutes of consumer protection. Lawsuits pile up against the “Health Plans” (HP). Consortium for Brazilian Accreditation (CBA) created in 2009, the first Brazilian standards for HP Accreditation. Authors assessed the adequacy of health services provided by a major health nationwide insurer in Brazil (Bradesco Saúde) that underwent a preparatory survey (mock survey) and 13 months later, a survey for accreditation. The objective was to compare the evolution of health care adequacy indicators between the surveys. Methods: Authors created specific indicators to assess adequacy of health care services provided to beneficiaries. The table below identifies the indicators: Health network construction: qualitative/ quantitative criteria to build network; Health services provided within a reasonable period: performance guarantee to delivery health services; Quality management: analysis of technical data from providers; Information to beneficiaries about network: communication to enrolled members about services; Special services for vulnerable and risk populations: services that meet vulnerable and risk member’s needs; Special services for patients with chronic diseases: disease management program; Safety of surgical procedures rendered: request evidences of processes / procedures to ensure surgeries are performed correctly and safely; Safety against risks of infection: request to hospitals evidence that they adopt protocols for hygiene and hand washing to reduce the risk of infections associated with healthcare. Authors analysed CBA surveys reports carried out at Bradesco Saúde to identify compliance with the indicators. Results: The indicators were considered Met (M) if the response to its requirement were answered “yes" or” always “and settled for at least four months. Were considered Partially Met (PM) if the answer was “usually" or” sometimes “and if compliance had been established between five and 11 months. The indicator was Not Met (NM) if the answer was “occasionally” “or" never” and settled for less than one month prior to the survey. Table 1-‐ Indicators compliance results Indicator Health network construction Health services provided within a reasonable period Quality management Information to beneficiaries about network Special services for vulnerable and risk populations Special services for patients with chronic diseases Safety of surgical procedures rendered Safety against risks of infection September2010 survey PM M NM M M M NM NM October, 2011survey M M M M M M PM PM Conclusion: Significant differences between the overall compliance of the indicators between the two surveys were observed. In the accreditation survey Bradesco Saúde obtained an overall compliance of 93.75 % against 56.25% observed in the mock survey. Adequacy of health services of Bradesco Saúde improved significantly between the surveys. Recommendations: Authors recommend Brazilian “Health Plans” to implement accreditation as a tool to improve quality and safety of health care services to members. References: Consortium For Brazilian Accreditation. Health Plans: CBA manual for evaluation of Health Plans Methodology II. Rio de Janeiro: CBA, 2011. Supplementary Health Agency (Brazil). Index of complaints: performance of operators from the rate of complaints. Rio de Janeiro, (2012?). 1668 The Dental Field And The Promotion Of Quality, Safety And Evaluation Of Practice * 1, 2 1 3 Bella St Clair , David Greenfield , Andrew Georgiou 1 2 Centre for Clinical Governance Research, Australian Institute of Health Innovation, University of New South Wales, Oral Health 3 Services, Royal Far West Children's Health Service, Centre for Health Systems & Safety Research, Australian Institute of Health Innovation, University of New South Wales, Sydney, Australia Objectives: Transparency regarding quality and safety in dental services remains opaque. The study’s purpose was to review a cross section of the dental literature to identify how the field addresses quality, safety and evaluation issues in practice including the role accreditation programs may play. Methods: Dental journals were identified and ranked according to the ISI Web of Knowledge impact factor ratings. The leading ten journal publications from 2013 were reviewed and categorised according to the article focus. Only original articles were considered; reviews, commentary and technical notes were excluded. Articles were thematically analysed and categorised using a two pass coding system. First pass coding was by thematic analysis. Themes were rolled into six categories and a second pass was conducted against the designated categories. Results: There were 144 dental journals identified. No international dental journal was identified that has a specific quality and safety focus. From the top 10 journals, in 2013 a total of 1372 research articles were published and six common categories were identified (Table 1). Table 1. Breakdown of published papers by thematic category Theme Innovation and development in dental materials Physiology or biological responses to treatments Promotion of technique and methods Population health Patient management Standards, quality and safety Total Number of articles and percentage n (%) 450 (33) 401 (30) 377 (28) 86 (6) 44 (3) 3 (<1) 1372 (100) The majority (91%) of 2013 papers focused across three themes: innovation and development in dental materials; the physiological or biological responses to treatments; and promotion of specific techniques or methods. In the literature reviewed, there was little evidence of the role of standards and quality assurance or improvement methodologies. There were no specific inclusions of accreditation processes. Of the 47 papers examining patient management and standards, quality and safety, the leading contributors came from United Kingdom (14, 24%) and Germany (7, 14%). A further 19 countries had four or fewer contributions each. Conclusion: The snap shot of 2013 dental research reveals that the highest tier of dental academic journals has a strong focus on development and innovation in materials and practice. Discussion of quality and safety issues comes through the literature via developments in theory of dental practice. Research addresses this in an indirect way although it can be seen in practice through the intersection with patient management issues. Accreditation programs are yet to be discussed in the dental literature. Dentistry is a field which is examining how it explicitly addresses quality and safety issues. Positive steps have been made with the inaugural dental workshop at the ISQua conference last year. Research has been limited to a small number of countries and discussion has yet to be seen across the field more broadly. There is opportunity to build upon the quality and safety aspects of material and methods development for advancing broader evaluation questions. A key issue for each country is to find means of evaluation that are relevant to dental services and take account of differences in dental practice structure and processes. By engaging in international forums and research, the dental field can learn from other health care sectors and across countries to build robust evaluation systems for the field. 1670 Practice And Theory In Health Service Accreditation Standards Development: Does The Reality Match The Rhetoric? David Greenfield* 1, Marjorie Pawsey1, Deborah Jones2, Jeffrey Braithwaite1 1 Centre for Clinical Governance Research, Australian Institute of Health Innovation, University of New South Wales, 2 Australian Council on Healthcare Standards, Sydney, Australia Objectives: Governments around the world are using health service accreditation standards to influence quality and safety practices and clinical outcomes. While standards methodologies are advocated, including by International Society for Quality in Health Care (ISQua), the application and applicability of these remain under-‐researched. The aim of this study was to compare the development process for accreditation standards against best practice guidelines. Methods: The study investigated the Australian Council on Healthcare Standards (ACHS) standards development processes for the Evaluation and Quality Improvement Program, version 5 (EQuIP5). A four step multi-‐method study was conducted across 2013-‐2014. First, a literature search and analysis identified best practice for standards development. Second, secondary data analysis of the ACHS standard development process was performed. Third, focus groups and interviews with health service staff were conducted to ascertain users’ perspectives on accreditation standards and their development. Fourth, triangulation and review of the findings by an expert panel were undertaken. Results: The major reference material identified in the policy (or grey) literature was the ISQua International Principles for Health Care Standards (version 3, 2007) and Australian Productivity Commission Standard Setting and Laboratory Accreditation Research Report (2006). The best practice advocated in the Productivity Commission Report was compiled from a range of sources, including Standards Australia’s and international standardisation guides and the World Trade Organisation’s Code of Good Practice. The ACHS EQuIP5 development process comprised seven phases, with 24 specific steps, spanning a period from January 2008 to March 2012. The phases were: prepare the review; collect and analyse data; develop new standards; gain comment on the draft standards; conduct pilots, produce the standards; and evaluate the standards review process. Health service staff comments mapped to five of the seven phases of standards development. In particular, they emphasised the need to keep standards abreast of current practice, stakeholder participation in developing and commenting on the standards and appropriate resources for the task. The expert panel review identified that the ISQua Principles and Productivity Commission Report best practice guidelines each advocated six of the seven phases of the ACHS standards development; ISQua Principles did not specifically mention the evaluation of the standards review process. Conclusion: This study investigated how the reality matched or diverged from the rhetoric in the revision of a set of health service standards. The best practice method advocated for the development of standards are revealed to be both practicable and a useful conceptual framework. In this instance, reality and rhetoric are closely aligned. Three factors emerged as critical in the development process task: an explicit structured approach; the engagement and incorporation of feedback from stakeholders; and making available considerable resources, including time. To produce current credible evidence based accreditation standards all three factors are needed simultaneously. The study reinforces for standard setting and accreditation agencies the value of the ISQua Principles as a framework to guide their development and revision processes. Consideration should be given to the inclusion of the additional phase of the evaluation of the standards review process. 1864 Accreditation Of Dialysis Centres: Qualitative Analysis Of Its Impact In Argentinian Facilities Ricardo A. Otero1, Ricardo Herrero2, Mercedes I. Laurenza3, Lilian Peuscovich3, Ricardo Durlach* 3 1 Technical Direction, 2General Management, 3Technical Area, ITAES, CABA, Argentina Objectives: General Objective: To explode and describe the processes over which the Accreditation had a significant impact and the main difficulties faced by institutions in preparation for accreditation, according to the perspective of the management body of Dialysis Centres accredited by Instituto Técnico para la Acreditación de Establecimientos de Salud -‐ ITAES-‐ (Technical Institute for the Accreditation of Health Facilities). Specific aims: a. To describe the organisational processes over which accreditation of Dialysis centres had a significant impact, according to the Institutional Medical Director and the head nurse points of view. b. To describe the main difficulties faced by Dialysis centres during the preparation for accreditation, according to the Institutional Medical Director and the head nurse points of view. Methods: It is a qualitative, retrospective descriptive study. A survey was conducted among all head nurses and institutional medical directors of facilities accredited by ITAES. In parallel a subgroup was selected to participate in a Delphi panel. This general method of prospective allows to build a group of expert’s consensus, based on the analysis and reflection of a problematic issue. The selection criteria of respondents and experts consulted was their belonging to a dialysis centre in Argentina that had implemented any of the accreditation programs held by ITAES: either the Accreditation itself or the progressive preparation program. This program consists in a working methodology in which an accreditation expert appointed by ITAES, advices the institutions in their preparation for accreditation, detecting the extent of compliance of each quality standard of the ITAES accreditation manual, making suggestions and recommendations aiming to correct diversions. Results: According to the results obtained so far, the issues that present major difficulties for its improvement are related to the standardisation and normalisation of processes and procedures, the documentation ordering and systematisation, the organisation of waste and supplies repositories and the constant actualisation of the different written records. This abstract is a conceptual synthesis of the obtained results. Each of the evaluated scopes will be developed and described in detail on the occasion of the 31st ISQua International Conference Conclusion: Currently there are 87 Dialysis centres accredited by ITAES, which represents nearly 25% of the entire centres in the country, located in 17 provinces of Argentina. In terms of the public health 40% of the population under dialysis treatment, held it in a centre under an ITAES accreditation program. This wide scope and the experience gained allow us to think that, although accreditation is a methodology that covers health care institutions individually, it has the potential of generating a positive impact in the whole health system. Along this, Accreditation and mainly the preparation for its meeting, allow the building of a shared vision and engagement with the processes of ongoing improvement, all in all, for the generation of an organisational culture change towards quality. 1900 Using Advanced Technology To Support Clients, Assessors And Staff Through Accreditation Stephen Clark* 1 1 Group Chief Executive Officer, Quality Innovation Performance (QIP), Milton, QLD, Australia Objectives: To learn how Quality Innovation Performance (QIP) successfully developed integrated information systems to support clients, assessors and staff in accreditation. To discuss how integration of systems can support multiple business functions and clients. To learn how internal development of information systems and software can lead to a streamlined system that offers long-‐term flexibility. Methods: QIP provides accreditation and certification services to a range of industries. Australian health reform has led to clients requiring assessment against multiple standards. In recent years QIP has invested in developing its own information systems, a database and software tool to support clients with a streamlined self-‐assessment process. Utilising information management to support business objectives and standard five in the International Accreditation Standards for Healthcare External Evaluation Organisations. The software was developed internally at QIP which has ensured that continuous quality improvements can be made. This approach has ensured a flexible system that can be adapted as needed should factors such as external environment changes, new accreditation Standards, or an organisation merger occur. Results: The web-‐hosted relational database and software are integrated. The software consists of five applications: Standards Editor, iExpress, Reports Editor, AccreditationPro and the QIP website. AccreditationPro is externally facing to support clients and assessors. Integration ensures data accuracy and that duplication of work is minimised. A critical component to the system is Standards Editor, which enables standards and assessment methodology to be setup. The software can accommodate standards of any size, structure or complexity. An integrated system ensures a consistency of standards interpretation and assessment for both clients and assessors. Recent software development has equipped Standards Editor to house numerous standards. This expansion will benefit clients that assess against multiple sets of standards; further streamlining the accreditation process. A web-‐based tool, AccreditationPro was one of the first electronic self-‐ assessment systems in Australia and can be used across multiple standards. AccreditationPro is designed to simplify, streamline, automate and integrate provision of accreditation and certification services. All QIP and Australian General Practice Accreditation Limited (AGPAL) clients and assessors use this software tool. The tool captures assessment ratings, required improvements and commentary. In addition, AccreditationPro facilitates compliance data analysis for training, benchmarking and standards development. Integrated into AccreditationPro is QbAY, an online resource library to support clients with educational resources, information sheets and research. The primary operations database, iExpress, functions as customer relationship management software. Linking and sharing data with AccreditationPro, the system holds general information about clients, assessors and the accreditation process. Conclusion: The flexibility of five systems, and internal resourcing, ensure that continuous improvements can be made. Expansion and modification of the current systems were required after the formation of QIP in late 2012. Post-‐merger integration has driven a new era in QIP’s information systems. A new client relationship management tool will be launched to ensure even better support and capabilities. The information systems and software continue to be improved and support business objectives. QIP and AGPAL were re-‐accredited against the ISQua Standards in 2013 and excelled in standard five: Information management. 1986 Validation Of Patient Safety Indicators In The French Context François Chollet1, Cyrille Colin1, Adrien Beauveil1, Antoine Duclos* 1 1 Pole Information Medicale Evaluation Recherche, Hospices Civils de Lyon, Lyon, France Objectives: Originally developed in the United States from large administrative databases, global use of Patient Safety Indicators (PSI) is challenging due to the singularity of information systems and coding rules in each country. We compared PSI validity before and after adapting their production algorithms to the French context. Methods: Original algorithms of three PSI (PSI-‐7 Catheter related bloodstream infection, PSI-‐12 Postoperative pulmonary embolism or deep vein thrombosis following hip or knee arthroplasty, and PSI-‐13 Postoperative sepsis) were transposed to the French nationwide hospital database and calculated in 2010. Using medical record from 1614 patients with potential adverse events in 49 hospitals as the gold standard, false positive cases were identified to refine algorithms. PSI positive predictive values (PPV) were estimated using mixed models and compared between original and refined algorithms. Results: Positive predictive value for PSI-‐7 was 14.3% (CI95%, 10.9 to 18.6) and 20.1% (14.8 to 26.8) before and after refinement. After focusing the production algorithm on accurate diagnosis and procedural codes, PPV for PSI12 went from 82.7% (68.4 to 91.3) to 90.1% (75.9% to 96.4%). Based on specific codes for sepsis and systemic inflammatory response syndrome, PPV for PSI-‐13 was significantly improved from 44.7% (39.1 to 50.3) to 70.2% (61.3 to 77.7) (p<0.0001). Conclusion: Adaptation and validation of original PSI in the context of every country is necessary before utilising these metrics for tracking hospital performance. 2011 A Decision Framework As A Critical Enabler For Improving Consistency Of Inspector’s Findings Kim Faure* 1, Carol Marshall2, Sulaiman Sulau3, Bafana Msibi4 1 Independent Consultants, 2Chief Director, Office of Health Standards Compliance, NDOH, Pretoria, 3Statistical and Actuarial Science, University of the Witwatersrand, Johannesburg, 4Director Inspectorate, Office of Health Standards Compliance, NDOH, Pretoria, South Africa Objectives: The Office of Health Standards Compliance (OHSC) is a newly established independent regulatory body responsible for promoting and protecting the health and safety of users of health services. The OHSC achieves this objective by conducting inspections of health establishments in South Africa for compliance to norms and standards as set out in the National Core Standards document [1]. The regulated entity is the health establishment which needs to provide evidence that it has put in place systems, processes and procedures that promote and ensure quality health services. Inspectors of the OHSC required a tool to guide their judgement that a Health Establishment has met compliance requirements in a transparent, consistent and credible manner. Methods: Various judgement and audit methodologies were evaluated from international and local accreditation organisations (CQC, ISQUA, JCI, and Auditor General of South Africa). These were adapted and tested through workshops with the inspectors and then used during mock or training inspections from the period February 2013 onwards. The decision framework encompassed criteria for intent, sufficiency, reliability and validity of evidence: ! Determining the intent of the measure (or question) requires positioning of it in the context of the standard and criteria statements that it relates to; ! Sufficiency is about the quantity of evidence and multiple pieces of evidence may be needed to demonstrate sufficiency; ! Reliability is about the quality of the evidence to draw a conclusion. It is influenced by how appropriately the evidence answers the question and how reasonable it is given the resources of the health establishment. This is where the content of the evidence is examined to determine whether it contains the required information and descriptions that the measure calls for. ! If at any point, the inspector is uncertain or alternatively if evidence is suspect then the inspector needs to validate the evidence through triangulation of information from different sources. New inspectors appointed from March 2013 onwards were taught the decision framework on orientation and then supervised in their implementation of the framework during mock inspections. The framework also became the basis upon which the inspector’s quality controlled their findings both within and between the various inspections. Results: Testing of decision framework from February 2013 during mock inspections showed improved consistency and reduced variability of assessed scores between inspector teams compared to the period before that. Feedback received from inspector within teams, indicated that the framework allowed newer inspectors to question a judgement by a more experienced inspector and so improved the understanding of all and improved consistency in application of the framework with each new cycle of inspections. Conclusion: A tool that guides inspector’s decision making on compliance is a critical enabling mechanism to improving the consistency and credibility of inspection results. It ensures that a team of inspectors is much more likely to reach the same conclusion on the situation found within a hospital or clinic. And it improves the manner in which the regulatory body establishes sound grounds upon which to base its judgement of compliance or non-‐compliance against a set of quality norms and standards. References: [1] National Department of Health, “Towards Quality Care for Patients; National Core Standards for quality in Health Establishments in South Africa”, February 2011. 2094 The Evolution Of Brazilian Public Hospitals In Process Improvement Of Quality And Safety Isis D. Querino* 1, Daniella B. Romano1, Izolda M. Ribeiro2, Nidia C. Souza1 1 Quality Departament, 2Sustentability Departament, Alemão Oswaldo Cruz Hospital, São Paulo, Brazil Objectives: This study aims to report the experience and evolution of Restructuring Public Hospitals Project in partnership with Ministry of Health, which uses the standards of the Joint Commission International as a reference to redesign processes and enhance quality and safety in Brazilian Public Hospitals. Methods: This is a quantitative study, reporting experience type, built from the results of diagnostic evaluations and the first educational evaluation at 06 public hospitals in the Southeast, Midwest and Northeast Regions of Brazil. Results: In the diagnostic evaluation, the 5 hospitals were not using any method of quality and safety at the beginning of the project, showed percentages of compliances ranging from 26.1 to 37.3%. The only hospital that has ever worked with concepts of Quality and Safety at the beginning of the project was a result of 51% compliance. In the diagnostic evaluation, the mean compliances of all hospitals were 34.5% and the standard deviation 8.1%. The chapters presented the best results in common by at least 75% of the hospitals were: Prevention and Control of Infections with mean 58.7% and standard deviation 5.9%; Governance, Leadership and Direction with mean 65.5% and standard deviation 10.9%; Management of Information with an average of 56.2% and a standard deviation of 11.9%.Regarding conformity, the chapters that had lower performance in common by at least 75% of the hospitals were: Care of Patient averaging 24.8% and standard deviation of 9.5%; Medication Management and Use averaging 22.9% and standard deviation of 8.7%; Patient and Family Education with 15.8% and a standard deviation of 9.3%; Quality Improvement and Patient Safety with an average of 11.6% and a standard deviation of 11,3%; Facility Management and Safety with average of 23.3% and a standard deviation of 12,2%; Patient International Safety Goals with an average of 5.3 % and a standard deviation of 3.7%.In educational assessment, after 12 months, the average compliance among hospitals was 55.8% and a standard deviation of 7.1%. Among the chapters presented the lowest performance compared to diagnostic evaluation, we obtained the following developments in relation to compliances: Care of Patients with a mean of 41.4% ( increase of 16.6% ←) and standard deviation of 15.9% , Management Medication and Use with an average of 45.5% (←22.6%) and standard deviation of 22.1%; Patient and Family Education 26.2% (←10.5%) and standard deviation of 4.2%; Quality and Patient Safety with an average of 47.2% (←35.6%) and standard deviation of 7.6%; Facility Management and Safety in averaging 42.1% (←18.8%) and standard deviation of 4.6%; Patient International Safety Goals with a mean of 13.7% (←8.5%) and standard deviation of 14.3%. Conclusion: According Maximian (1997), the Brazilian current scenario in the context of a globalised economy, is in a worrisome situation where institutions no longer bear the costs associated with poor-‐quality, among them: high expenses with increasing morbidity and mortality, spending "rework" and outlays inefficient process. To Manzo (2009), new requirements as they relate to professional skills, behaviour change, engagement of professionals in search of goals and objectives proposed, along with permanent and continuous improvement of care is required. Thus, initiatives to improve processes and implementation of quality and safety programs, tend to address the above difficulties, as evidenced in the results achieved by the Project. Adding to this, the preparation of National Patient Safety Program, created in April 2013, reinforces the need for culture change in Brazilian Health Services. 2117 The Accreditation Canada Stroke Distinction Program: A System Approach To Excellence Wendy Nicklin* 1, Bernadette MacDonald1, Lacey Phillips2, Stephanie Carpenter2 1 Accreditation Canada, Ottawa, Canada, 2Program Development, Accreditation Canada, Ottawa, Canada Objectives: The Distinction Program is a rigorous and highly specialised accreditation program. Accreditation Canada developed the Distinction program to improve quality and drive excellence in services that have the largest impact on population health, have high service volume, and represent high cost to the health care system. Methods: The Stroke Distinction Program was developed in partnership with the Canadian Stroke Network and is based on the Canadian Best Practice Recommendations for Stroke Care. The program was released in 2010 and has seen growing interest across Canada. To achieve Distinction status, Stroke programs are evaluated bi-‐annually on highly specialised standards and must meet requirements that have been designed to address the key areas of quality and safety for their area of care. Stroke programs demonstrate adherence to established protocols; collect, track, and submit indicators and thresholds; and meet requirements for excellence and innovation in their respective field. As well, these programs must also meet requirements on client and family education. To maintain the award on an ongoing basis, indicator data must be submitted and thresholds met. The Distinction Program encompasses the continuum of stroke care from first response to acute stroke care and rehabilitation. Stroke programs are encouraged to apply for Distinction as a system of care. This regional approach reflects the inclusion of all relevant partners within the system of care. Stroke systems are evaluated at the individual site and service level and as an integrated stroke system. Although stroke services vary by province in Canada, a systems approach supports improved efficiency in service delivery. Results: As of the beginning of 2014, six Canadian health care organisations have achieved Stroke Distinction and three more are enrolled in the process and anticipating on-‐site surveys in the coming year. The program has also started to attract international interest. The requirements to achieve and maintain Stroke Distinction status are rigorous. As more stroke programs seek the award, capacity is being built across Canada. Through use of protocols and the submission of indicator data, teams are tracking their progress and meeting established national thresholds. This translates into better outcomes for Canadians and more consistent care across Canada. Conclusion: Stroke programs that achieve Stroke Distinction demonstrate excellence in care and establish themselves as distinct among healthcare providers across Canada. As uptake of the Stroke Distinction program continues to increase and with the release of Trauma Distinction in September 2014, Accreditation Canada will continue to support improved care and outcomes for Canadians. 2194 Embedding Patient Safety Into The Accreditation Canada Emergency Medical Services Program Wendy Nicklin* 1, Diana Sarakbi2, Stephanie Carpenter2, Amanda Bonacci3 1 Accreditation Canada, Ottawa, Canada, 2Program Development, 3Business Development, Accreditation Canada, Ottawa, Canada Objectives: As Emergency Medical Services (EMS) care in Canada becomes more complex, Accreditation Canada continues to provide consistent and relevant national standards that foster quality improvement and patient safety. The accreditation program requirements are applied to EMS clients that are independent organisations, or may be integrated within the broader accreditation program, if the EMS services are delivered under the authority of a regional health authority. This presentation will highlight recent enhancements to the program. Methods: Through national consultation across Canada, Accreditation Canada recognised the expanded responsibilities for EMS care providers. Some of these expanded responsibilities stemmed from the complex nature of pre-‐acute care including administration of drugs and treatments, as well as EMS providers spending more time with unstable patients who are waiting for services due to Emergency Department overcrowding. These factors have increased the need for a focus on patient safety in EMS. The Accreditation Canada EMS standards were enhanced through a rigorous process including the guidance of an expert Standards Working Group, consultation across Canada, and pilot testing. An in-‐depth literature review highlighted priority areas for patient safety in EMS. As a result, the decision to add Accreditation Canada Required Organisational Practices (ROPs) to the EMS standards was made. ROPs are evidence-‐based practices that mitigate risk and contribute to improving the quality and safety of health services. Results: Based on the review process, the EMS standards were revised with content specifically focused on quality improvement frameworks, communication between providers and partner organisations, and dispatch procedures and protocols. Enhancements to the tracer process to assess this content during the on-‐site survey process were also made. Eight ROPs were added to the EMS standards to align with identified risk areas in patient safety: Information Transfer, Multiple client identifiers, Infusion pumps training, High-‐alert Medication concentrations, Narcotics safety, Hand-‐ hygiene audits, Hand-‐hygiene education and training, and Sterilisation processes. ROPs provide a focus area for organisations to enhance patient safety and carry considerable weight toward an organisation’s accreditation decision. Conclusion: The most recent enhancements to the EMS standards, including the incorporation of the ROPs, were released to EMS provider organisations in January 2013 and have been evaluated since January 2014. These changes have strengthened the Accreditation Canada program significantly, enabling organisations to specifically address key areas of patient safety in EMS. Additional areas of patient safety have been prioritised as the Accreditation Canada program for EMS providers continues to evolve. Accreditation Canada is strengthening the program for medical transport and introducing standards content for air transport. Accreditation Canada will continue to monitor how the EMS accreditation program is responding to the changing landscape of EMS care in Canada in 2014 and beyond. 2197 The Evolution Of Healthcare Accreditation Standards: Are Principle-‐Based And Outcome-‐Focused Standards Feasible? David Greenfield* 1, Marjorie Pawsey1, Anne Hogden1, Jeffrey Braithwaite1 1 Centre for Clinical Governance Research, Australian Institute of Health Innovation, University of New South Wales, Sydney, Australia Objectives: There is a growing practice internationally to base industry regulation on principles and focus on outcomes. The study aim was to identify key factors from this type of approach to regulation and consider whether they can be applied to the development and implementation of healthcare accreditation standards. Methods: Over 2013-‐2014 the international literature on principles-‐based and outcome-‐focussed regulation in the economic, political, legal, accounting and business fields was reviewed and key factors were identified and categorised. The factors were assessed by expert accreditation researchers to consider their relevance to healthcare accreditation standards. Results: From the literature scan, key factors central to regulation based on principles and an outcome-‐focused approach were grouped into seven categories: identifying the need for standards; the development process; characteristics of the standard; based on principles; focusing on outcomes; assessing and addressing risk; and non-‐negotiable rules. Additionally, a further four factors were identified that were considered important for implementation of regulations or standards: the role of the assessing agency; the role of the healthcare organisation; the creation of a learning community; and transparency and accountability of the system. The collective application of these 11 factors, as an integrated model, to revise healthcare accreditation standards might have merit. Together they represent a model to be used to: evolve accreditation programs and standards, from their current attention on structure and process; reinforce the importance of stakeholders being cognisant with continuous quality improvement designs; and provide opportunities for individual organisations to be innovative and flexible regarding quality and safety issues. Simultaneously, the model promotes consistency, transparency and accountability by reinforcing the need for a “learning community”, where stakeholders across the sector work collaboratively to derive a shared understanding. Stakeholders are encouraged by the model to view the whole system as well as their particular contribution to it. Furthermore, the model highlights the necessity to see the development and implementation of standards as an integrated package. Conclusion: Healthcare can evolve and improve through learning from other industries. An approach to regulation based on principles and an outcome-‐focus, seems an applicable and feasible model for healthcare accreditation standards. The caveat is, however, that accreditation stakeholders need prior experience with a program that has been grounded in a structure and process framework. Sequenced in this way ensures that stakeholders’ understanding and use of continuous quality improvement philosophy, techniques and actions are firmly embedded and collectively shared. The implication and challenges of healthcare accreditation standards emphasising principles and outcomes is twofold. First, being principle-‐based provides organisations with potential flexibility and opportunities to be innovative in their quality and safety activities. The challenge for accrediting agencies and surveyors is being able to survey reliably against such principles and to resist being prescriptive in their expectations. Second, being outcomes-‐focused makes a direct link between the standards and patient results, thereby addressing a longstanding criticism of accreditation programs. The challenge, however, is identifying measures and indicators relevant, widely used and acceptable across the sector. 2223 National Healthcare Facility Licensing And Accreditation System – Establishment Stage Faleh M. H. Ali1, Jamal R. Khanji* 2, Aisha A. Al Ali2, Tamer S. Farahat2 1 Supreme Council of Health, Doha, Qatar, 2Healthcare Quality & Patient Safety Department, Supreme Council of Health, Doha, Qatar Objectives: To enhance the delivery of healthcare quality and patient safety within healthcare facilities through standardisation. Methods: Review and analysis of current Qatar Healthcare Strategy and all existing process and policies healthcare system, followed by getting feedback and inputs from all stakeholders related to the project. The following are the major project steps: 1. Development of Quality Policy & conceptual framework: Development of a National Quality Policy for the State of Qatar which will provide the basis from which to develop an effective licensing and accreditation system. 2. Development of Licensing and Accreditation Standards: Development of a tailored suite of healthcare facilities licensing and accreditation documentation based on an international accredited set of previously developed standards. 3. Development of a Licensing and Accreditation Process: Ensuring the effective and efficient operation of all aspects of the licensing and accreditation system. 4. Inspectors & Surveyors Development: Development of the processes, and education program which will support the Supreme Council of Health to ensure effective regulation. 5. Development of Facility Education Program: Development of a healthcare facilities education program for the State of Qatar which help the healthcare industry to prepare for and comply with the new regulatory criterion. 6. Development of Information Management System: Development of a specialised software system which will enhance regulatory compliance and ensure greater transparency. Results: New set of regulatory standards which will enhance the current licensing standards and procedures and link them to the newly developed Accreditation standards for Healthcare facilities as a single system for the state of Qatar. The licensing standards will be interwoven and be considered a first stage of the process. This will enable healthcare facilities to achieve their licensed status and be ready for the next step which is the first level of accreditation .these will be two distinct processes but owned by the same organisation in an attempt to have a single healthcare facility regulator. In the future, we aspire to have two independent regulatory bodies; one for healthcare facilities and the other for healthcare practitioners. Both regulatory bodies will be linked and operated collaboratively toward re-‐shaping and enhancing healthcare system for the state of Qatar. Conclusion: In the future, when National Healthcare Facility Licensing and Accreditation System has successfully delivered its outputs, all healthcare providers will work within an uniform regulatory framework. 2380 Disease-‐Specific Evidence Of Higher Quality Of Care In Accredited Hospitals: In The Case Of Acute Heart Failure Yuichi Imanaka* 1, 2, Noriko Sasaki1, Hiroshi Ikai1, Naohito Yamaguchi2, 3 1 Department of Healthcare Economics and Quality Management , Kyoto University Graduate School of Medicine , Kyoto, 2 Japan Council for Quality Health Care, 3Department of Public Health, Tokyo Women’s Medical University, Tokyo, Japan Objectives: To examine the influence of hospital accreditation on the quality of care provided to Acute Heart Failure (AHF) patients. Methods: We identified 16,252 AHF patients hospitalised between 2010 and 2011 using claims data based on the Japanese Diagnosis Procedure Combination patient case-‐mix classification database (the Quality Indicator/Improvement Project: QIP). Hospital process indicators including diagnostic tests and therapeutic interventions were examined. Using these process indicators, we compared quality of care for hospitalised AHF patients between hospitals accredited by the Japan Council for Quality Health Care (JCQHC) and non-‐accredited hospitals. In order to examine the effects of hospital accreditation on processes of care, Odds Ratios (ORs) were calculated using logistic regression models for the various indicators after adjusting for the effects of patient demographics, disease severity (such as New York Heart Association functional class), and co-‐morbidities at admission for non-‐accredited hospitals, using accredited hospitals as the reference category. Results: The study sample consisted of 265 hospitals located across Japan, varying in hospital size (ranging from 30 to 1,106 beds), case volume (ranging from 1 to 332 cases during the study period), teaching status as verified by the Japanese Circulation Society (65.9%), the number of cardiologists per hospital (ranging from 0 to 20), and hospital ownership (public: 53.9%; private: 46.1%). After adjusting for patient factors, non-‐accredited hospitals were found to be associated with lower utilisation of standardised processes of care, relative to accredited hospitals (diagnostic echocardiography: ORs [95% Confidence Interval] 0.79 [0.72–0.88], pacemaker implantation: 0.50 [0.28–0.89], and cardiac resynchronisation therapy with a defibrillator: 0.38 [0.14–1.04]). In contrast, ORs of the intravenous dopamine or dobutamine administration and cardiac resynchronisation therapy without a defibrillator, which may require careful adoption, showed significantly higher associations with non-‐accredited hospitals (ORs: 1.45 [1.29–1.63] and 3.45 [1.52– 7.82]). Non-‐accredited hospitals were therefore observed to have poorer performances in standard processes of care while possibly providing excessive care in AHF patients when compared with accredited hospitals. Conclusion: In this large-‐scale multi-‐institutional analysis, JCQHC-‐accredited hospitals were found to be associated with higher utilisation of major standardised diagnostic tests and therapies, whereas non-‐accredited hospitals may possibly be providing high quantities of unwelcome invasive care. Our findings show that hospital accreditation may reflect quality of clinical care in hospitalised AHF patients. Disclosure of Interest: Y. Imanaka Grant/Research support from: the Japan Society for the Promotion of Science, Other: Grant/Research support from Ministry of Health, Labour and Welfare, N. Sasaki: None Declared, H. Ikai: None Declared, N. Yamaguchi: None Declared 2491 High Performance In Accredited Hospitals Kelly Alves* 1, Ana M. Malik2 1 Mestranda and Gestão da Qualidade, FGV and Amil, 2Docente, FGV, São Paulo, Brazil Objectives: In the accreditation processes we observe that institutions adhere to develop monitoring tools to ensure the care and management of administrative performance. The effectiveness of that management is seen through the reports of the evaluation procedures for accreditation services and the related indicators monitored by the institution. The aim of this study was to determine whether the accreditation contributes to high performance, and if there is a positive correlation between indicators and external assessment reports by accreditors showing high performance. Methods: We analysed and tracked four accredited hospitals in south eastern Brazil that perform monitoring and care management indicators, with minimal historical series of three (3) years and have spent at least one or two reviews by accreditors. The internal database of these hospitals and direction of these, relating them with the results of the assessment reports were evaluated by accreditors. Results: It was possible to identify that the trend of improvement ranged from 38 % to 69 % of the indicators assessed by these hospitals. There are some hospitals that despite the support has remained stagnant or worsening, the variation was 5% to 12 %. Relating to the reports, we can verify that they are directly related. Considering the assessment reports by accrediting containing the description of favourable points, on 50 % of the sample reported the indicators that showed high performance and observations or non-‐conformances, 2 % were directly related to indicators of poor performance. Conclusion: It is possible to observe a favourable trend in the indicators of accredited hospitals. It may be a possible form of assistance for the implementation of high performance monitoring, but through this sample, we can see that it is not certain that the period of two years high performance is monitored for all indicators. Accreditation can be a favourable factor for management indicators but we cannot say with this study that it is a unique factor for high performance in hospitals. References: • Rowe, A. K., Savigny, D., Lanata, C, Victora, C. G. How can we achieve and maintain high-‐quality performance of health workers in low-‐resource settings? The Lancet. Volume 366, Issue 9490, 17-‐23 September 2005; • Baker, Stacy L. MSEd; Beitsch, Leslie MD, JD; Landrum, Laura B. MUPP; Head, Rebecca PhD, DABT. The Role of Performance Management and Quality Improvement in a National Voluntary Public Health Accreditation System. Journal of Public Health Management & Practice: July/August 2007 -‐ Volume 13 -‐ Issue 4 -‐ p 427–429. • O.A. Arah, N.S Kazingo, D.M.J. Denoy, A.H.A. Temasbroek, T. Custer. Conceptual frameworks for health systems performance: a quest for effectiveness, quality, and improvement. Inte.J.Qual.Health Care (2003)15(5)377-‐398. 2513 Towards A Culture Of Innovation In Health And Social Services François Sauvé* 1 1 CQA, Quebec, Canada Objectives: In Canada and worldwide, most Health and Social services’ organisations lack suitable mechanisms to develop incentives in order to facilitate an organisational culture of innovation. Nonetheless some organisations are making it happen. Through a scientifically based approach, we have taken our researches to another extent in order to measure and certify organisations that satisfy the requirements of our recognised definition of an innovation-‐friendly environment[i] in the Health and Social services sector. [i] http://milieunovateur.ca/ Methods: We evaluate the existence of a culture of innovation through a self-‐assessment method involving 45 questions and 61 statements that are covering all the management functions of an organisation in the Health and Social services sector. Based on 20 years of experience in the field of accreditation, the main topics of the assessment cover the 22 norms of the normative framework of standards, developed by the Conseil québécois d’agrément[i]. These standards were then categorised into 7 variables that we consider are at the forefront of the innovation process. These are variables are to be understood through the following assessment perspectives: ! To get involved: Assess the involvement of the strategic vision at the top and mid management level of the organisation; ! To collaborate: Assess inter-‐disciplinary, knowledge exchange, great achievements and failure within or outside the organisation and learn from benchmarking; ! To think different: Assess the ability to think out of the box and the internal process to generate new ideas; ! To take risks: Assess the acceptance and willingness to take risks; ! To valuate: Assess the ways to valuate innovation and its results as well as the people involved in the process; ! To subscribe: Assess the means used to facilitate an innovation-‐friendly environment by also taking into account the needs and expectation within the organisation ! To measure: Assess the automatic use and references to indicators in order to monitor projects and measure their impact. [i] http://www.cqaqualite.ca/en/accreditation Results: Beyond information and communication technologies (ICTs), innovation in the Health and Social services sector is crucial, too, at the management functions level of any organisation. Milieu Novateur is a tool designed and developed to valuate through a recognised certification those organisations of the Health and Social services sector in Québec that are putting innovation at the heart of their strategic vision. The certification is also working as an incentive to promote and push for more innovation in this specific sector. The way the researches[i] were conducted and the product was developed allow it to be suitable for and implemented at the international level. [i] ACTEMIS, « Assurance Innovation », www.actemis.com ; AFNOR, «Innovation, recherche et normalisation: comment favoriser les interactions?», Rapport d’étude, 2008; ANVAR, «Processus de développement d’un projet innovant»,2001. Conclusion: Almost two years of implementation allow us to draw first lessons regarding what makes an innovation-‐ friendly environment in the Health and Social services sector in Québec. First lesson learned is that innovation requires preparation, support and leadership. The second lesson we have learned is that an innovation needs to be systematically measured. That is why an additional 7th variable dedicated to the notion of cross cutting measurement of an innovation-‐friendly environment was added recently to the approach. 1150 The Effect Of Government Supervision On Quality Of Smoking Cessation Counselling In Midwife Practices SF Oude Wesselink* 1, HF Lingsma1, JP Mackenbach1, PBM Robben2, 3 1 Public Health, Erasmus MC, Rotterdam, 2Dutch Health Care Inspectorate, Utrecht, 3Institute of Health Policy & Management, Erasmus University, Rotterdam, Netherlands Objectives: The Dutch Health Care Inspectorate performed supervision to improve smoking cessation counselling by midwives. Aim of the study is to evaluate the effect of this government supervision on midwife practices that provide smoking cessation counselling. Methods: For evaluation of the intervention different designs and comparisons were used: before and after study and RCT design with post-‐measurement only. The intervention from the Dutch Health Care Inspectorate included assessments with questionnaire and personal report to practice (A), announcement of deadline when all practices should comply with professional norms (B), and assessments with site visits and personal report to practice (C). Target of the supervision were primary care midwife practices in the Netherlands, who provide care to about 80% of pregnant women. Study outcome was smoking cessation counselling, evaluated in online questionnaires to midwife practices. Smoking cessation counselling was measured as use of a minimal intervention strategy with associated steps (V-‐MIS), and presence of preconditions for smoking cessation counselling. Registry data were used to investigate training of midwife practices in smoking cessation counselling. Statistical analyses included linear and logistic regression and Kaplan-‐Meier curves. Results: Practices that were assessed with a questionnaire (A) showed some improvements in smoking cessation counselling compared to controls. After announcement of the deadline (B) almost all elements of smoking cessation counselling improved. Use of V-‐MIS increased substantially from 28% to 80% and setting a quit date increased from 21% to 61% of pregnant smokers. However, no difference in smoking cessation counselling was observed between practices that were visited (C) and their controls. Also no differences between intervention and control groups were found for training of midwife practices in smoking cessation counselling. Nevertheless, after the supervisory activities, the participation rate in training of both intervention and control group practices increased significantly. Conclusion: Major improvements in smoking cessation counselling over time were observed in the total population of midwife practices. In this time period enforcement of the Inspectorate took place. Individual site visits and questionnaires to midwives by the Inspectorate had a minimal effect on the smoking cessation counselling performed by the midwives. In the absence of alternative explanations, we conclude that improvements over time are at least partly attributable to the supervisory activities by the Dutch Health Care Inspectorate. 2391 Quantity Of Accredited Hospitals In Brazil Armando G. De Oliveira Junior* 1 1 Department of Medicine and Nursing, from the Center of Biological and Health Sciences, Universidade Federal de Viçosa, Viçosa, Brazil Objectives: Identify the total number of accredited hospitals in Brazil and distribution of these hospitals in five regions of the country. In order to observe which regions are most advanced in the accreditation process and the amount of certifications of four in the country: the Organização Nacional de Acreditação (ONA), the Joint Commission on Accreditation of Hospitals (JCI), the Accreditation Canada International's (ACI) and the National Integrated Accreditation for Healthcare Organizations (NIAHO®), are present in these states. Methods: The study was regarded as exploratory type. The research had a qualitative and quantitative treatment. Data were collected in the months of January and February, 2014, through the official websites of the Organização Nacional de Acreditação (ONA), Consórcio Brasileiro de Acreditação (CBA), Det Norske Veritas (DNV), Instituto Qualisa de Gestão (IQG), on the internet and via information request by email along to these organs. Results: According to the data collected, in Brazil there are currently 214 hospitals accredited by the Organização Nacional de Acreditação (ONA), according to the Brazilian Accreditation Manual establishing three seals of hospital quality: • • • Level 1: Accredited (Security), Level 2: Full Accredited (Integrated Management) and Level 3: Accredited with Excellence (Excellence in Management), distributed in 06 hospitals in the North, 12 in the Midwest, 19 in the Northeast, 29 in the South and 148 in southeast. In the Southeast, in the state of São Paulo we have 92 accredited ONA, 23 at Level 1, 22 Level 2 and 47 Level 3, Minas Gerais 30, 06 in Level 1, 09 Level 2 and 15 Level 3, Rio de Janeiro 20, 11 Level 1, 04 Level 2, 05 Level 3 and Espirito Santo 06, 01 Level 1, 01 Level 2 and 04 Level 3. 29 In the South, 13 in Paraná, 03 Level 1, 05 Level 2 and 05 Level 3, Rio Grande do Sul 08, 03 Level 1, 02 Level 2 and 03 Level 3 and Santa Catarina there are 08, 03 Level 1, 04 Level 2 and 01 Level 3. The Northeast has 19 hospitals, 07 Bahia, 01 Level, 03 Level 2 and 03 Level 3, Ceará 03, 01 Level 1, 01 Level 2 and 01 Level 3, Pernambuco 02, 01 Level 1 and 01 Level 3, Sergipe 01 Level 3, Maranhão 03 Level 2, Alagoas 01 Level 3, Rio Grande do Norte and Paraíba 01 each Level 1 and Piauí has no accredited hospital. The Midwest of Brazil 12, 08 in the Distrito Federal, 02 Level 1, 04 Level 2 and 02 Level 3, Goiás has 02 hospitals Level 1, Mato Grosso do Sul 01 Level 1 and Mato Grosso 01 Level 3, and finally the North totalling 06, the state of Pará has 02 in Level 2 and 02 Level 3, Amazonas 01 Level 1 and Amapá 01 Level 1, the states of Acre, Roraima, Rondônia and Tocantins have not yet accredited hospitals. Another accrediting body, the American Joint Commission International (JCI) has accredited 24 hospitals in Brazil in "Hospital" program, 14 in the state of São Paulo, 04 in the state of Rio de Janeiro (Southeast), 04 in Rio Grande do Sul (South) and 02 in Pernambuco (Northeast). The Canadian Council on Health Services Accreditation (CCHSA), has 21 accredited hospitals in Brazil, there are 20 in the Southeast: 13 in Sao Paulo, 04 in Rio de Janeiro, 02 in Minas Gerais and 01 in Espirito Santo, in the southern of Paraná there is 01 CCHSA accredited hospital. The National Integrated Accreditation for Healthcare Organisations (NIAHO) has 04 accredited hospitals in the Southeast, all in the state of Minas Gerais. Conclusion: The Southeast region has more than half of accredited hospitals in Brazil and most of them in the state of São Paulo, then the South, Northeast, Midwest and North, respectively in number of accredited hospitals. 2531 Application Checklist For Self-‐Evaluation Of The Intensive Care Unit Angela Zerbielli* 1, Helidea Lima1, João Pantoja2, Priscila R. Toledo1 1 Qualidade e Segurança do Paciente, 2Diretoria Medica Corporativa, Rede D'or/São Luiz, São Paulo, Brazil Objectives: To demonstrate the applicability of the experience of a tool for evaluating a process finalistic a hospital -‐ Intensive Care Unit -‐ through a formatted checklist from the theoretical framework proposed by Donabedian (1) " structure -‐ process -‐ outcomes " allowing improved management . Methods: An assessment in the intensive care unit according to the criteria of the proposed tool -‐ self-‐assessment checklist of ICU. For the formatting of this instrument criteria of the relevant legislation (4) and the basis of the study by the European Society of Intensive Care (3), constituting a pattern of structure, processes and outcomes that each unit should cover were used. The instrument was formatted with adequacy criteria with different weights: 31.8 % relating to structuring, 48.2 % related to processes and 20 % regarding the results. In the final evaluation of the adequacy ranges of outcomes according to Table 1 were considered. Table 1 : % of adequacy, Adequacy %, Very High 90.1 to 100 %, High 80.1 to 90 %, Medium 60.1 to 80 %, Low 40.1 to 60 % , Very Low 0 to 40% Results: Intensive Care Units were evaluated in 15 private hospitals in a Hospital Network, located in the south eastern and north eastern Brazil. We observed 53 % of hospitals have very high level of fitness. The greatest opportunities for fitness (low fitness %) refers to the adoption of protocols Associated Pneumonia Community Protocols of stroke (ischemic and haemorrhagic) and adequacy of the contents of Alta. There is a culture focused on patient safety with total suitability for items relating to the use of risk scores, contractualization between sectors / processes, flow of event notification, prevention protocols associated pneumonia (VAP), prevention of bloodstream infection (BSI), prevention of urinary tract infection (UTI) and monitoring indicators. Conclusion: The application of self-‐assessment checklist allows the identification of best practices among hospitals in the network, allowing greater exchange of knowledge and at the same time, the assessment of the status of the unit in relation to one another, encouraging the search for the best performance. The final assessment of all units allows the network manager corporate actions with gain scale. The methodology provides for annual reassessments in order to monitor the performance improvement. From the application of this tool in other ICU checklists were developed for evaluation of other finalistic processes of hospitals (emergency operating room, paediatrics and paediatric care units). References: 1. Donabedian. Basic approaches to assessment: structure, process and outcome. In: Explorations in Quality Assessment and Monitoring (Donabedian A.) vol I, pp. 77-‐125, Ann Arbor , Mochigan: Health Administration Press. 2. Porter, M. E. , Teisberg , E. Rethinking health : strategies to improve quality and reduce costs . New York: Bookman, 2007. 3. Prospectively defined indicators to Improve the safety and quality of care for critically ill patients: a report from the Task Force on Safety and Quality of the European Society of Intensive Care Medicine ( ESICM ) , January 2012 -‐ Intensive Care Medicine 4. RDC Resolution No. 7 of 24 February 2010. 1203 Integration Of Clinical Guidance, Quality Assurance And Research Activity In Danish Primary Care Lars Morsø* 1, Lars Henriksen1, Peter Qvist1 1 Centre for Quality, The Region of Southern Denmark, Middelfart, Denmark Objectives: This study developed and tested an electronic questionnaire for clinical guidance in Danish primary care, while using a centralised server to allow quality assurance and research activities. Methods: There are often barriers to the implementation of evidence-‐based assessment sheets, questionnaires or tools for clinical guidance. One barrier is how to integrate these ‘technologies’ into diverse types of non-‐standardised electronic patient record systems, while maintaining centralised data collection for quality assurance and research activities. For assessment of low back pain (LBP) in Danish primary care a ‘meta-‐system’ (DAK-‐E Datafangst) was devised by the General Practice Quality Assurance Unit in the Region of Southern Denmark. The system allowed an electronic version of a specific LBP questionnaire to pop-‐up whenever a diagnostic code for LBP was entered. This pop-‐up function was activated regardless of the type of electronic patient record system being used by the GP (General Practitioner). This solution required consensus of a common communication interface that would be integral to all 15 of the GP electronic patient record systems. Results: Test of the ‘meta-‐system’ shows that once the GP enters a specific diagnostic code the system is able to activate the relevant pop-‐up allowing completion of the LBP questionnaire together with the patient. After completion the ‘meta-‐ system’ automatically calculates and displays a relevant classification score which guides the GP’s clinical decision making by triaging the patient into a clinical relevant subgroup. In addition to the support for clinical decision-‐making, the ‘meta-‐system’ also creates quality assurance information that potentially allows GPs to compare the classification profile of their patients with that of other GP clinics. Furthermore the centralised pooling of data into a register allows generation of data for research purposes. Finally, this electronic data collection can readily be linked to other health and population registries as all citizens in Denmark have a unique personal register number (CPR). This is in line with the tradition of registry-‐based research in Denmark. Conclusion: Through the use of a ‘meta-‐system’, integration of an electronic version of a patient centred guidance tool into GP clinics was achieved despite the presence of diverse and non-‐standardised electronic patient record systems. This ‘meta-‐ system’ creates opportunities for support of the clinical decision making by GPs while also enabling quality assurance and research activity across clinics. 1488 Cost-‐Effectiveness Of Dabigatran And Rivaroxaban Versus Warfarin In Management Of Non-‐Valvular Atrial Fibrillation In Estonia Rainer Reile* 1, Lutsar Katrin1, Triin Võrno1, Raul Kiivet1 1 Department of Public Health, University of Tartu, Tartu, Estonia Objectives: Despite the higher cost compared to warfarin, the use of new oral anticoagulants for stroke prevention has increasingly risen since 2010 in Estonia. This study evaluates the cost-‐effectiveness of new oral anticoagulants dabigatran and rivaroxaban compared to warfarin in patients with non-‐valvular atrial fibrillation in Estonia. Methods: We developed an independent Markov cohort model simulating natural course of atrial fibrillation to analyse the cost-‐ effectiveness of new anticoagulants – dabigatran and rivaroxaban – compared to standard warfarin treatment. Data on disease transition probabilities and quality of life estimates for different treatments was derived from published literature. Treatment costs and costs associated with atrial fibrillation and treatment complications were obtained from Estonian Health Insurance Fund 2010-‐2012 data. In the base-‐case scenario a hypothetical cohort of 1000 65-‐year old patients with atrial fibrillation was followed in three month cycles for 35 years. Different treatment regimens were evaluated from the payer’s perspective for avoided complications, differences in costs and Quality-‐Adjusted Life-‐Years (QALYs). Incremental Cost-‐Effectiveness Ratios (ICER) were calculated comparing new anticoagulants to warfarin treatment. Results: In the base case scenario, 0.39 QALYs with total cost of 11,563€ per patient were gained in dabigatran and 0.23 QALYs with total cost of 10,681€ in rivaroxaban treatment arm compared to warfarin. ICER per QALY for dabigatran was 20,696€ and 30,125 € for rivaroxaban compared to warfarin treatment. Compared to no-‐treatment, new anticoagulants added 1.06–1.20 QALYs with ICER ranging from 7734 to 7970 € per QALY. In sensitivity analysis comparing anticoagulants with no treatment scenario, ICER for dabigatran was in the range of 6028 – 14,313 € and for rivaroxaban 6221 – 14,546 € per QALY, being most influenced by change in time perspective, discount rate and medication costs. Conclusion: The findings from our purpose built cost-‐effectiveness model using real-‐life data on cost inputs from Estonia were favourable for new oral anticoagulants. ICERs for dabigatran and rivaroxaban compared to warfarin and its most influential input variables in sensitivity analysis were generally in accordance with previously published findings. Therefore it is likely that dabigatran and rivaroxaban could be accepted as cost-‐effective alternatives to warfarin in patients with non-‐valvular atrial fibrillation in Estonia. 1572 Establishing Electronic Database For Conservation Of Birth Records Spreading Over 7 Decades Irfan A. S. Valliani* 1, Huma Naz1, Muhammad Bilal1, Ali Dino Khowaja1 1 Aga Khan Hospital for Women and Children, Kharadar, Aga Khan University Hospital, Karachi, Pakistan Objectives: Establishing an electronic database and conservation of manual birth records into electronic database (A decade per year), from 1942 to 2010. Introduction: The Aga Khan Hospital for Women and Children, Kharadar is the first hospital of Aga Khan Development Network, Established in 1924. It catered more than 100 thousands births till 2011. Due to unavailability of computing system in past, traditionally the birth record had been maintained on paper The main challenges of the system was hard retrieval, retention and security of the record. This project aimed to develop a process to transfer these huge of number of records into an electronic database with proper validation process for easy retrieval, retention and safety. Methods: We used Deming’s cycle for this project execution. In the planning stage, team had analysed the problem via data collection from existing process and designed a workflow process to provide the change. The old system needed more manpower and time approximately 2-‐3 hours to retrieve the data from the manual record as records were kept on paper. Afterwards we designed software solution to record all the birth records, all these entries were passed from 3 tier reviewing and approving mechanism to validate and authenticate the process. We put this on pilot testing and added one year record in the initial phase. We also did system audits which resulted in further optimisation in the process. After successful pilot phase, we implemented this system as our permanent method of birth record keeping. Results: The project has yielded the following outcomes: ! Accessibility: An easy access to the birth records from the past.(25000 records have been converted), ! Increased External customer satisfaction: Issuance of old birth certificate is made possible through system which saves addition time of customer.(Previously it took a week period to issue the birth certificate but now in one working day, reducing 85% delay in issuance of birth certificate), ! Increased Internal customer satisfaction: Since, the Medical Record staff will no longer need to extract data from manual registers, the satisfaction level has increased, ! Increased Utilisation of Workforce: Implementation of this project decreased workload and utilisation of resources, on an average 100 minutes per record retrieval are saved, ! Decreased chances of errors: The three task management levels ensure error free record, ! Improved Efficiency: Access to the data and printing of birth certificates requires a few clicks only, ! Sustainability of the Birth Record: Electronic database has ensured that the data will be preserved and sustained. Implementation of this project improves customer satisfaction, increased work efficiency, decreased workload and utilisation of resources. Conclusion: Use of technology for preservation of historic data is mandatory. Creating an electronic database for conservation and retrieval of almost 100 years old birth record data is reliable and efficient. 1742 Implementation And Assessment Of A Nursing EMR System In Taiwan In Chang* 1, Li C. Hung2, Wei W. Chen1, Wun L. Kuo1 1 Medical Informatics, 2Nursing, National Cheng Kung University Hospital, Tainan, Taiwan Objectives: To improve the communication of clinical service in Taiwan, a pilot project of nursing EMRs (Electronic Medical Record system) has been implemented and assessed in National Cheng-‐Kung University Hospital (NCKUH) in 2013. The implementation experience of this project was proposed and the assessment result is shared to encourage the use of information technology to enhance the communication effectiveness in healthcare. Methods: A systematic literature review was performed to evaluate the need of inpatient clinical communication using EMR to replace the traditional paper form. A nursing EMRs was developed which used HL7-‐mandated codes to facilitate the patient nursing record exchange between Intensive Clinical Unit (ICU) and general nursing stations. A multidisciplinary team of quality circle project of NCKUH was organised in 2013. A PDCA method was adopted to monitor the frequencies of the patient nursing EMR enquires between ICU and general nursing stations. Data collection included group discussion, monthly meeting, and statistics of nursing EMR enquires. The data were analysed periodically and systematically. Results: Six improvement plans were identified and proposed: 1) expanding the storage of nursing EMRs, 2) adding a nursing EMR enquiring function linking nursing records of ICU and general nursing stations, 3) increasing training hours to enhance user’s perception of nursing EMR, 4) creating user’s incentives, 5) building an EMR knowledge management system to help users, 6) setting a standard procedure of enquiring nursing EMR. After a seven-‐month implementation and three-‐month assessment periods, the average frequency of nursing EMR enquires increased from 0.77 to 2.58 times per patient monthly. The number of EMR users increased significantly and the user group expanded from nurses to physicians and insurance staff. The cost of printing paper and room space saved up to 15,400 US each year. Conclusion: Through the implementation and assessment of the nursing EMRs in NCKUH, our study has proved that the use of nursing EMRs could replace traditional paper nursing records, improve the clinical communication and enhance patient safety significantly. We believe the implementation and assessment of the NCKUH case will be beneficial to other healthcare organisations dealing with the clinical communication and EMR paperless issues. 1764 Comparison Between Manual And Automated Methods For Erythrocyte Sedimentation Rate (ESR): A Tertiary Care Hospital Study Sadia Inam* 1, Lubna Khaleeq2, Muhammad Shariq1, Bushra Moiz3 1 Heamatology, Aga Khan University And Hospital, 2Hematology, Aga Khan Hospital and University, 3Hematology, Aga khan University and Hospital, Karachi, Pakistan Objectives: To compare manual method of ESR estimation with automated method in order to improve the turn-‐around time of the test. Methods: The study was conducted at Haematology section of Clinical Laboratories of the Aga Khan University Hospital. It was a prospective study. Time duration was 2 months (from Sept to Oct, 2013) blood samples were drawn in sodium citrate tube. Analysis of various samples was done by using Westergren tube and Bio-‐Griener SRS 20/II. SPSS version 19 was used for statistical analysis. Patients from both sexes and all age groups were included in the study. Blood samples which were not in proper proportions to the anticoagulant, strongly lipemic, haemolysed samples were excluded from the study Results: Total 100 samples were taken into consideration. Among these 100 samples age range was 1-‐90 years, with a mean age of 36.9 years. There were 56 females and 44 males. The correlation of co-‐efficient between two methods was 0.98.Analyses gave a mean value of 31.4 by manual and 31.9 by automated method. Conclusion: There was no marked difference between the mean values by both the methods therefore; manual method can be replaced with automated instruments. 2561 Computerised Of Diagnosis For Patients Sumaré State Hospital, Brazil: Development Of A System For Remote Report For Investigations Pathology Ana Julia S. Medeiros1, Eliana F. D. Rocha2, Ricardo M. Gimenez* 2, Carlos E. M. Antunes1 1 Nurse, 2IT, Hospital Estadual Sumaré, Sumaré, Brazil Objectives: Reduce the time between sample collection and results delivery to the patient, so that treatment, if necessary, be initiated as soon as possible, ensuring patient safety. To enhance this process, which was done completely manually in institution, the IT (Information Technology) sector computerised since the test request, and typing of the report by an independent laboratory providing results directly in the electronic patient record in the institution until the impression of these results and other administrative controls. Methods: The Pathological Anatomy is an essential procedure in the hospital routine, because it defines the diagnosis of various diseases with high morbidity and mortality, such as malignant neoplasms and granulomatous diseases, which require a responsive and specific therapeutic approach. Thus, the entire process involved in routine pathology laboratory -‐ pre -‐ analytical, analytical and post -‐ analytical -‐ should reach beyond efficiency until the release of the final report, ensuring full access to the result by the physician attending the patient. These tests are performed by an external laboratory. Requests were made manually by physicians, referred to the external laboratory that after the finalisation of the report, it was printed in the lab and sent to hospital via transport. All control of examinations and reports sent was also done manually. When the report was received by the hospital, it was separated and placed in the physical patient record and after this process was available to the requesting physician. After computerisation, doctors began to prescribe in the ERP (Enterprise Resource Planning) and laboratory typing the report directly into the system. All care and administrative information came to be viewed in reports developed in the system. Results: With computerised, there was a general improvement in the process. The reports are classified according to the results obtained: (malignancy, pre-‐cancer and non-‐cancer) through specific reports and is prioritised based on the classification marking of a return visit to the requesting physician for diagnostic analysis. These classifications are reported by the laboratory at the time of typing the report. The doctor can see all the tests that the patient underwent, from any computer in the hospital, through the developed system. There was a significant reduction in response time as passed on to the patient and consequently the treatment results. According to a survey conducted in the year 2012/2013, the time between viewing the results and diagnosis increased from 20 days to 10 days, with a gain in quality and patient safety far superior to the previous process. Moreover, the information retrieved from the database can also be used for medical and scientific research, since the institution is a teaching hospital. Conclusion: We observed that computerisation has brought many benefits, not only to the hospital, but mostly for the patient. Any time you win an early diagnosis of patients diagnosed with cancer, it could mean a cure. This multidisciplinary work integrated the IT sector with the care areas, showing the importance of information technology in healthcare. 1989 Evaluation Of The Effectiveness Of Information Technology In The Medical Process Priscila P. Cachucho* 1, Camila L. Segalla2, Massanori Shibata Júnior3, Ronaldo Kalaf4 1 Quality and Pharmacy, 2Nursing, 3Medical board, Hospital Santa Helena, Santo André, 4Vice president, Santa Helena Assistência Médica, São Bernardo do Campo, Brazil Objectives: Demonstrate the benefits of information technology and the effectiveness of the system itself developed in the safe administration of medications in patients admitted to the intensive care unit. Methods: The medication process is complex and comprises a series of interrelated decisions and actions involving professionals from different disciplines. Failures involving drugs can occur not only in the administration as well as at any stage of the medication cycle from purchasing, receiving, identification unitisation, prescribing, dispensing, administering up. In this context, the department of information technology is critical to the alignment of the strategic goals of the company in the search for more efficient and safe processes. The system for safe medication administration's Hospital Santa Helena was developed with own resources, involving 4 professionals in information technology and 5 health professionals (doctor, nurses and pharmacists). The project, created in Delphi 7 with Oracle database, started in 2006 and was completed in three years. In the present study 2 periods were compared: 2006 to 2008, corresponding to the execution phase of the project, and from 2009 to 2013, following implementation of the computerised system. The electronic tool developed by the institution ensures the checking of batches blocked by ANVISA (National Health Surveillance Agency) medications, it's validity conference, blocks the prescription drug in cases of patients with hypersensitivity to the active ingredient, ensures that medication previously checked is actually intended for the patient and assists in effective inventory control. For this, the patient receives a wristband with barcode, through which check is made at the time of application of the drug, which also receives the barcode from receipt. Employees involved in each step of the process have also badge with barcode, allowing traceability of all drug flow and everyone involved. The results were treated statistically using the median, allowing a more accurate assessment of the data collected. Results: In the period of project implementation, there was a median of 385 drugs dispensed for each hospitalised in intensive care unit patients. After deployment of the system, despite the increase of 334.1 percent on the amount of drugs dispensed per patient, the rate of failure events related to the medication process was 0.60 percent, corresponding to 11 cases in 2013. Conclusion: Studies indicate that failures involving drugs are among the main events in hospitals around the world and it is estimated that the administration of wrong drugs is of the order of 36 percent. Thus, the development of its own electronics has enabled the Hospital Santa Helena differentiate against competitors, ensuring a safe and effective process that allows error rates in administering drugs far below those reported in the literature, which is why it is visited by reference in safe medication process by institutions recognised for its high standard of excellence. 1034 The Advantages Of Accepting Interns Of The Health Information Manager Program For Trainers In Practical Training Sites Haruka Murai* 1, 2, Mayumi Takeyama2, Chihiro Saito2, Tetsuya Kamei1, 2 1 School of Health Sciences, 2Graduate School of Health Sciences, Fujita Health University, Toyoake, Japan Objectives: A two week internship for students who major in Health Information Management in universities or at professional schools is mandatory, in order to be eligible to take the Health Information Manager (HIM ) examination in Japan. For schools, assigning students to healthcare facilities is not an easy task because not all of the facilities accept interns. While internship is essential and effective for students before they take the exam and go out into society, it can sometimes become a burden for the onsite trainers. In order to make practical training productive for both the students and the onsite trainers, the positive and negative effects should be understood, and the internship preparation programs should be improved. Methods: A questionnaire survey regarding the effects and strains for the onsite trainers was carried out after the internship period in the year of 2013. Questions included inquiring about the trainer’s characteristics such as the number of years of experience, their reputation regarding the rate of time to instruct students, and the possible influence they had on their students. Based on the responses, the attributes of actual trainers, their observations about the advantages and the burdens of instructing students, and the perceived advantages and disadvantages were all analysed. Results: Fifty-‐nine responses from eighteen practical training sites were obtained. Ninety-‐two percent of on-‐site trainers concluded that accepting interns was indeed beneficial. On average, trainers perceived that they spent thirty percent of their energy to train the students. Sixty percent of on-‐site trainers were non-‐executive employees. Nearly fifty percent of the trainers had less than three years’ experience in their position. Regarding the advantages of accepting interns, the following were considered as positive effects; that training students could become an opportunity to improve instruction ability (88% agreed), to predict the areas where interns would likely make errors and to explain them in advance to avoid mistakes (85%), to be able to listen to the various opinions of junior colleagues actively (69%), and to generate employment (66%). It was considered as not effective that trainers could learn the current healthcare system from students (91%), could learn how to use the PC (83%), and could scold or chide junior colleagues (63% and 61% respectively). Conclusion: Practical training is critical for students not only to be eligible to take the exam but also to experience the reality of their tasks and their workplace environments in the future. Along with the advantages for interns, it was shown that training students was also a good educational opportunity for on-‐site trainers. Schools can sort both positive and negative effects for interns and trainers involved to develop in class programs to diminish the negative effects of practical training sites. At the same time, advantages can be enhanced to expand the number of practical training sites. It can also lead to a stable assignment for students, and fruitful employment. 1039 Student-‐Led Quality Improvement: A 3-‐Year Follow Up Study Of Kleihauer Testing And Anti-‐D Administration Nikola Lilic* 1, Kalpa Jayanatha2, Peter Stone3 1 Department of Surgery, University of Auckland, 2Department of Medicine, Middlemore Hospital, 3Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand Objectives: In 2010/11 a student-‐led quality improvement (QI) project to align hospital practice with international guidelines led to a statistically significant improvement in Kleihauer-‐Betke (KB) and Anti-‐D administration. Our objective was to determine if improved healthcare delivery from student-‐led QI could be sustained long-‐term. Methods: 6th year medical students carried out methodologically identical audits at yearly intervals starting in 2010. The audits were performed at the same large tertiary New Zealand obstetric unit by acquiring an anonymised list of all Rhesus D (RhD) negative mothers with RhD-‐incompatible births within a 3-‐month period from the centralised New Zealand Blood Bank (NZBB) records. Anti-‐D administration and KB testing information was then obtained from the hospital’s online laboratory program and manually crosschecked with NZBB records, the sole dispensing centre for Anti-‐D. Following the first audit in 2010, the medical students initiated an intervention. The intervention involved creating an evidence-‐based hospital protocol for KB testing and Anti-‐D administration. The new protocol was placed on the hospital’s intranet and circulated to obstetricians, residents and midwives. Repeat audits, with identical methodology, were then completed at yearly intervals. We conducted logistic regression and post-‐hoc contrasts after adding 1 to the zero in one cell. Statistical significance is cited at p 0.05. Analyses were conducted in Stata v12.1. Results: The initial study in 2010/11 showed an improvement in KB testing following the intervention by 80% (95% CI 0.73 – 0.86, p<.0001) and Anti-‐D administration by 13% (95% CI 0.06 – 0.20, p<.0001). Analyses of anti-‐D results and KB results both confirmed a significant effect of year: Chi2 20.2, p=0.0001 and Chi2 53.0, p <0.0001, respectively. In both cases there was a significant difference between year 2010 and each other year, and no significant difference between years 2011, 2012 and 2103. Year Women (n) KB test (%) Anti-‐D (95%) 2010 102 2 85 2011 163 82 98 2012 115 72.4 100 2013 82 75.6 100 Conclusion: We have shown that medical students can improve long-‐term healthcare delivery via QI projects and teaching. This has significant implications for advocating an increase in QI education in medical curricula, as not only does it have educational merit but it can also improve long-‐term healthcare quality and decrease costs for carrying out QI. In order to achieve such improvements it is important that the teaching involves a practical component, where students can carry out real life QI, and that there is support from senior clinicians. 1204 Can Prognostic Measurement Tools Automatically Be Applied Across Health Care Settings And Populations? Lars Morsø* 1, Peter Qvist1, Lars Henriksen1 1 Centre for Quality, The Region of Southern Denmark, Middelfart, Denmark Objectives: The objective of this study was to investigate the applicability of a patient completed prognostic questionnaire in different health care settings. Methods: The use of patient questionnaires in health care has highly increased during the last decade. The questionnaires are used for measurement of patient satisfaction, improvement, prediction of outcome or screening for risk factors that influence treatment. These questionnaires are usually developed and tested in a specific clinically setting. Often the results are uncritically referred from one health care setting to others, and the questionnaires are also applied to different patient populations than initially intended. Studies indicate that caution should be taken of this application across health care settings and populations without consideration. In this study 200 patients from Danish primary care and 920 patients from Danish secondary care completed the Start Back Tool (SBT). The SBT is a short prognostic questionnaire developed and validated in primary care to predict the risk of poor outcome for patients with Low Back Pain (LBP). The questionnaire classifies patients into subgroups of low, medium or high risk of poor outcome. In the study the predictive ability of the SBT was compared across health care settings by the use of Odds Ratios (OR). Results: The results showed that the baseline characteristics across the two cohorts were significant different in terms of episode duration (p<0.001), leg pain intensity (p<0.001) and close to significant on LBP intensity (p=0.059). While the distribution of the subgroup classification reflected earlier studies in the primary care cohort (low risk 35%, medium risk 41%, high risk 24%), the distribution into subgroups in the secondary cohort was different (28%, 32%, 40% respectively). When using activity limitation as outcome measure the predictive ability of the SBT in primary care displayed an OR of 5.2 of poor outcome in medium risk and an OR of 6.9 in high risk compared to the low risk subgroup. Comparably in the secondary care cohort the OR for medium risk was 2.4 and for high risk 3.3. This indicates that the predictive ability of the SBT was poorer in secondary care. Conclusion: The predictive ability of the patient completed prognostic questionnaire was not the same across the two health care settings. This study contributes to findings from earlier studies that caution should be taken when applying questionnaires and outcome measures across health care settings uncritically. To ensure reliable measurements across health care settings agreement on applicable methods are needed. Un-‐validated models should not be introduced in clinical practice. Therefore development of prognostic measurement tools should be performed in consecutive phases to ensure validation and quality assurance of the prognostic research. This is recommended to be done in the framework of development studies, validation studies and impact studies. 1276 Strategic Implementation Of Root Cause Analysis Education Program Enhances The Safety Climate In A Healthcare Organisation Yun-‐Ching Chen* 1, Fang-‐Yeh Chu1 1 Quality Management Center, Far Eastern Memorial Hospital, Taipei, Taiwan Objectives: To err is human! It is essentially not possible to completely avoid errors, however, it is of utmost importance to identify the potential system or process failures and do every effort to improve and/or prevent it once an error occurs in a healthcare organisation. Root Cause Analysis (RCA) methodology is a powerful tool to investigate the root cause of medical error and prevent it from happening again. An education program is conducted to disseminate the concept and commitment of Root Cause Analysis (RCA) in order to enhance patient safety culture in a medical center and expect to enhance the safety climate in every level of the organisation. Methods: The RCA Education Program was launched in 2010 and it enrolled at least one assigned member from each department of the medical center. Every enrolee participated in a well-‐structured workshop. The program was constructed and referred to the online RCA teaching materials from the National Patient Safety Agency in United Kingdom. The curriculum included a case-‐based discussion using the RCA methodology step by step and an abbreviated version of the RCA methodology suitable to be applied in minor event. Annual survey of patient safety culture was conducted using the Safety Attitude Questionnaire in Chinese (SAQ-‐C) since 2009. Results: From 2010 to 2013, a total of 167 staff from 86 departments completed the training program. Among them, 36 (21.6%) were physicians, 60 nurses (35.9%), 28 paramedical staff (16.8%), and 43 administrative staff (25.7%). Overall, 104 of 167 enrolees (62.3%) are leaders of different levels. The annual patient safety culture survey showed positive impact in the dimension of “Patient Safety Climate”. From 2010 to 2013, the overall positive attitude in the dimension of “Safety Climate in the Unit” of SAQ-‐C increased from 42.6% to 53% (p <0.01). Specifically, the positive attitude in “Medical errors are handled appropriately in this unit", "In this unit, it is difficult to discuss errors", and "The culture in this unit makes it easy to learn from the errors of others" increased from 68.4% to 77.1% (p <0.01), from 55.4% to 60.5% (p <0.05), and from 62.1% to 70.3% (p <0.01), respectively. Conclusion: Through the well-‐planned RCA Education Program and strategic implementation of linking personnel in each unit in a medical center, we successfully disseminated the concept into every level of the center and it effectively enhances the safety climate of the institute. 1354 Are Referral Information And Discharge Diagnosis Compatible? Lise Lund Håheim* 1, Anja Schou Lindman1, Jon Helgeland1 1 Norwegian Knowledge Centre For The Health Service, Oslo, Norway Objectives: The priority for elective treatment in the specialist health service in Norway is assessed at time of referral but ICD-‐10 codes allocated to the medical conditions are not specified. This study validates the accordance between referral information and ICD-‐10 discharge diagnoses of 20 conditions defined in ten selected priority guidelines in a review of medical records at selected hospitals. Methods: In the period 2008-‐2009, the Norwegian Directorate for Health introduced priority guidelines for elective treatment in the specialist health service within 32 medical specialties to define acceptable waiting times according to specific clinical priority. The main study uses data from the Norwegian Patient Register (NPR), which receives discharge diagnoses (ICD-‐ 10) and procedures from the hospitals. NPR is a central administrative system for registering all persons receiving treatment or waiting for treatment in the Norwegian specialist health service. Members of the groups developing the guidelines facilitated the code lists of the conditions of the guidelines. A structured selection process resulted in a review of 20 conditions from ten guidelines. Accordance or sensitivity was estimated overall, per hospital, and per condition. The study was sample sized to 100 patients per condition. In a review of medical records at four hospitals, the reason for deviation between referral and discharge was coded as clear accordance, poorly formulated referral, not sufficiently informative referral but adequate, or no accordance. Results: In all, 1,854 medical records were reviewed. Age ranged from one year to 108 years. More women were included (53.9% women and 46.1% men) as two conditions were of women only. Overall sensitivity was 0.93 (95% CI 0.92-‐0.94), for the individual hospitals ranging from 0.82 (95% CI 0.79-‐0.86) to 0.96 (95% CI 0.94-‐0.98). Overall sensitivity for different conditions ranged from 0.87 for hip osteoarthritis (n=100) to 1.00 for eating disorder (n=25). Hospital specific sensitivity values below 0.80 were 0.71 for hip osteoarthritis, 0.60 for psoriasis (serious or moderate), 0.60 for jaw infections, and 0.76 for heart valve disorder. The importance of correct codes was important, as Z-‐codes identified for haematuria did not correctly identify patients. Conclusion: The high level of estimated sensitivity gives confidence in using data from the NPR in analysing the effect of the introduction of the priority guidelines. A low level of sensitivity would indicate a need for further validation of the codes for the different priority guidelines. 1411 Nutrition Core Competencies: A Foundation For Pre-‐service And In-‐service Nutrition Training Endris Mekonnen* 1, 1, Mesfin Goji1, Tadele Bogale1 1 Engine, Jhpiego, Addis Ababa, Ethiopia Objectives: The objectives of the assessment were to identify gaps in nutrition education of undergraduate nutritionists, health workers and mid-‐level agriculture professionals and define nutrition core competencies for them. Methods: The Ethiopian Health and Nutrition Research Institute (EHNRI) in 2009 identified gaps in nutrition curriculum and training capacities of higher learning institutions in Ethiopia. To address these gaps and inform the National Nutrition Program (NNP), Empowering New Generations to Improve Nutrition and Economic opportunities (ENGINE) project conducted a nutrition core competency assessment in July and August 2012. Data was collected using in-‐depth interview with key informants from various relevant sectors including 12 pre-‐service institutions, and desk review of published and un-‐published documents. The data was transcribed, coded and summarised manually. Results: The assessment indicated that nutrition pre-‐service education was unable to equip nutrition practitioners with the desired competencies to provide good quality nutrition services. A key finding was that nutrition education was not task-‐ oriented and those involved in nutrition services were lacking the required knowledge, skills and behavioural competencies. Absence of nutrition skills learning facilities such as skills laboratory, equipment and supplies, and adequate number of classroom and practical nutrition instructors were documented as gaps of the training facilities. Nutrition education was not tailored to specific disciplines and the time allotted for nutrition courses was inadequate. Nutrition core competencies were identified for undergraduate nutritionists, various health professionals at different levels and for agriculture agents. Competency-‐based nutrition learning approach was introduced in 12 pre-‐service education institutions including four universities, four health science colleges and four agricultural Technical and Vocational Education and Training (TVET) colleges that will have significant policy and programmatic implications. Conclusion: Competency-‐Based Education (CBE) works based on the premise that people need to be taught and assessed on the knowledge, skills and attitudes required for effective performance of their work. One of the key steps in making nutrition training competency-‐based is identifying the desired nutrition competencies for those involved in nutrition service delivery. Once competencies are identified, the existing health and agriculture curricula should be strengthened by integrating the essential, but missing nutrition competencies. A discipline-‐specific and task-‐oriented nutrition education focusing on skills learning with adequate contact time is recommended. 1475 Patterns Of Antibiotic Use In Paediatric Outpatients With Acute Upper Respiratory Tract Infections In Korea From 2009 To 2011 Sun Mi Shin* 1, Ju-‐Young Shin1, Mi Hee Kim1, Byung-‐Joo Park1, 2 1 Korea Institute of Drug Safety and Risk Management (KIDS), 2Department of Preventive Medicine, College of Medicine, Seoul National University, Seoul, Korea, Republic Of Objectives: Acute Upper Respiratory Tract Infections (URTIs) are one of the condition in which antibiotics are not commonly recommended. This study was conducted to estimate the incidence of antimicrobial prescribing for URTIs among paediatric outpatients and to identify the national patterns of its use from 2009 to 2011 in Korea according to antibiotic classes, types of medical care institutions, physician specialties, and geographic regions. Methods: We used the National Patients Sample (NPS) database from the Korea Health Insurance Review & Assessment Service (HIRA) from 2009 to 2011, which is nationally representative sample of almost 50 million Korean population. We estimated the frequency of antibiotic prescribing for acute URIs in paediatric outpatients younger than 18 years. The proportions of each antibiotic class were calculated by year and absolute and relative differences were estimated. Also, we investigated the antibiotic prescribing rates and daily amount of prescribed antibiotics per defined population using DDD (Defined Daily Dose) according to type of medical care institution, physician specialty, and geographic region. Results: The overall antibiotics prescribing rate was 58.7% in paediatric outpatients with acute URTIs, which was higher than that in western countries. The annual rate of antibiotics prescription was slightly decreased from 60.5% in 2009 to 55.4% in 2011. The most commonly prescribed antibiotic was extended spectrum penicillin’s accounting for 55.2% of all antibiotic prescriptions. We observed significant increases in the proportions of third generation cephalosporin’s and macrolides with 40.7% and 16.7% of relative difference, respectively. Tertiary hospitals were less likely to prescribe antibiotics than primary and secondary, but they showed higher tendency to prescribe third generation cephalosporin’s. Variations by physician specialty and region were also observed. Conclusion: Despite the decrease in antimicrobial prescribing for children, proportions of third generation cephalosporin’s and macrolides were significantly increasing in antibiotic prescriptions. More education for appropriate antibiotic prescription for acute URIs are needed based on these findings. 1490 Impact Of A Short Protocolized Institutional Training On Adequacy Of Time Of Interventions In Septic Patients: A Before And After Study Fernando G. Zampieri1, Andreza P. Hamada2, Gisely M. Schrot* 2, Fernando Colombari1 1 Intensive Care Unit, 2Institutional Development, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil Objectives: To describe the impact of a short protocolized training course on the time elapsed from diagnosis to important therapeutic interventions in patients with severe sepsis and septic shock. Methods: We conducted a before and after study on a large tertiary hospital in Brazil. We evaluated the impact of a short (6h) training program aimed to increase the awareness of sepsis and the importance of timely interventions (time to antibiotics, blood culture sample drawing, lactate measurement, central venous oxygen saturation -‐ SvO2 -‐ measurement) in the management of septic patients. The training program consisted of clinical scenarios simulation and short classes. All health staff (nurses, respiratory therapists, nurse assistants and physicians) was trained during the first two weeks in October, 2013. We compared time between sepsis diagnosis and the before mentioned interventions before (from April to September) and after (November and December) the completion of the institutional training program. We also assessed compliance with the first hour bundle of the Surviving Sepsis Campaign recommendations (lactate measurement, blood cultures and appropriate antibiotics on the first hour after diagnosis)1. Continuous variables were tested for normality with Kolmogorov-‐Smirnoff test. Parametric variables were compared using t test. Mann-‐Whitney test was used for non-‐parametric variables. Categorical variables were tested with chi-‐square test. Results: A total of 136 patients with severe sepsis and septic shock were included. 94 (68%) patients were treated before and 42 (32%) after the institutional training program. The most common sources of infection were respiratory (39%), urinary (19%) and abdomen (18%). A minority of infections was nosocomial (7 patients, 5%). Mortality was similar between the before and after groups (38 versus 30%; p=0.8). Use of inotropes (dobutamine) and vasopressors (norepinephrine) was similar between groups (12% versus 9%, p=0.43 and 71% versus 57%, p=0.11, respectively). Time to first lactate assessment and time to measurement of SvO2 were shorter on the after group compared with the before group (97 [0-‐ 198] versus 11 [0-‐115.4] minutes, p=0.02 and 205 [25.5-‐704] versus 57.5 [0-‐428] minutes, p<0.001). Time to antibiotics and time to blood culture were similar between groups (p=0.25 and 0.11). More patients complied with the first hour bundle of the Surviving Sepsis Campaign Guidelines in the after group compared with the before group (45% versus 23%; p=0.01)1. Conclusion: A short institutional training program can raise awareness and reduce time delay of appropriate interventions for septic patients. The optimum way to train hospital staff should be further addressed on prospective studies. References: 1. Dellinger RP, Levy MM, Rhodes A, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013 Feb;41(2):580-‐637 1586 Trends In The Rates Of Complications, Failure-‐To-‐Rescue And 30-‐Day Mortality Among Surgical Patients In New South Wales, Australia (2002 To 2009) Lixin Ou* 1, Jack Chen1, Hassan Assareh1, Stephanie J. Hollis1 1 Simpson Centre for Health Services Research, Faculty of Medicine, the University of New South Wales, Sydney, Australia Objectives: Despite the increased acceptance of Failure-‐To-‐Rescue (FTR) as an important patient safety indicator (defined as the percentage of deaths among surgical patients with treatable complications), there has not been any large epidemiological study reporting FTR in an Australian setting nor any evaluation on its suitability as a performance indicator. We aimed to understand the trends and variation of rates of complications, FTR and 30-‐day mortality among surgical patients of pubic acute hospitals in a large health jurisdiction Australia. Methods: We conducted a population-‐based study on elective surgical patients from 82 public acute hospitals in New South Wales, Australia between 2002 and 2009. We explored the trends and variations of the rates of complication, FTR and 30-‐day mortality. We used a Poisson regression model to directly derive the Relative Risk (RR) after adjusting for a range of patient and hospital characteristics. Results: The average rates of complication, FTR and 30-‐day mortality were 14 per 1000 admissions, 14% and 6%, respectively. The rates of complications and 30-‐day mortality were stable across the study years but there was a significant decrease of FTR rate after 2006 coinciding with the establishment of the national and state peak patient safety agencies. There were marked variations in the three rates amongst the top quintile and bottom quintile hospitals for each of the four peer hospital groups. The largest principle referral hospital group had a significantly higher rate of FTR in comparison to the other three smaller size peer hospital groups (RR=0.78, 0.57, and 0.61, respectively). Conclusion: FTR showed promising property in response to the wide range of patient safety programs. The marked variations in the three rates between-‐ and within-‐ peer hospital groups indicate great opportunities for further quality improvement interventions where the three indicators could be reported regularly in Australia. 1725 Needs Assessment In Clinical Nursing Service Of Teacher Education Hui-‐Ling Lin* 1, Yueh-‐E Lin2, Yuk Sau High1, Wenpin Yu1 1 Department of Nursing, 2 Chang Gung Memorial Hospital, Lin-‐Kou, Taipei, Taiwan Objectives: As the number of hospitals with clinical nursing teachers’ increases, planning for teacher training programs occurs annually to enhance teaching capacity, improve retention rates, and increase the hospital’s overall competitiveness. Although evaluation of the current program has resulted in satisfactory outcomes, examining the needs of the nursing teachers and students during training can lead to higher success rates, strengthened interactive lessons, and increased capacity to guide student understanding and focus. Retroactive appraisal of the clinical nursing teacher training program combined with a needs assessment can lead to better new staff employment (currently 14%) and higher curriculum satisfaction (currently 3.9 with a 78% response rate.) Methods: A cross-‐sectional study to obtain representative sampling and collect date was used to evaluate the objective. Three stages were used to gather data with 328 clinical nursing teachers participating initially. The 1st stage involved using a retrospective questionnaire (Likert 5 point scale) to determine knowledge of current literature, understanding of current issues, and satisfaction with the current program. Twelve topics were assessed and sorted to determine which teaching goals ranked first in importance during the instruction of new staff. (See Table I) The 2nd stage focused on five courses that most needed improvement. Interviews with teachers and students combined with the use of references and an understanding of the needs of clinical practice allowed for the pinpointing of the courses that needed to be focused on. The five courses that were re-‐developed and integrated into the new curriculum included using learner centered clinical teachers to discuss roles and tasks, determining how to guide learners in interrelated areas of clinical care, encouraging and teaching teamwork, enhancing methods to assess learning outcomes for students including Mini-‐CEX and DOPS assessment and feedback, and integrating evidence based nursing into clinical teaching. (See Table II) The 3rd stage involved 302 nurse participants that evaluated the course after the redevelopment of the curriculum and provided a satisfaction measurement. (cf. Appendix III) Results: In this study, 328 participants started the first stage of the study, while 302 participants completed the entire study resulting in a 92% completion rate. Based on the results of the satisfaction questionnaires both prior to and after redevelopment of the curriculum, the new curriculum was found to be more effective and satisfactory. The pre-‐ development satisfaction measurement had an average of 3.9 points while the post-‐development satisfaction measurement had an average of 4.56 point resulting in an increase of 0.66 points. (See Table IV) Conclusion: After the initial assessment of the program, the redevelopment of the curriculum lead to a 0.66 point increase in satisfaction with the program from 3.9 predevelopment, to 4.56 post development. When examining the clinical findings and references, it was found that reviewing, examining, planning, and developing a more interactive learner centered curriculum which addressed the needs of the students resulted in higher student motivation and the creation of a positive learning atmosphere 1822 Using Smart Objectives Management To Build High Quality Of Cancer Care Pei-‐Chien Lu* 1 1 Nursing Department, Chang-‐Gung Memorial Hospital, Putzu City, Taiwan Objectives: Using target management to enhance the high-‐quality cancer care, enable the patients to receive appropriate assessment, health education and care, and to get qualified for Cancer Care Quality Certification. Methods: Setting SMART goals (Specific, Measurable, Attainable, Results-‐Oriented, Target Date), by three phases to perform mainly in data collection and setting up, personnel training and review. To develop a clear S goal -‐ achieving the schedule of high-‐quality cancer treatment certification including training and consensus seminars, to get a model-‐ ranking ward; measurable M goal -‐ to develop assessment form; attainable A goal -‐ the assessment criteria for the year 2013 cancer Care Quality certification criteria as the basis, taking site investigation in practical operation and nursing personnel records, medical records, and other supporting documents in written, and hire experts for external audits; results-‐oriented R goal -‐ defects found from the blood cancer ward and the ten major cancer wards were discussed in weekly morning meeting, the summary of recommendations were made and submitted to the related section executives for improvement, Setting date T goal -‐ from February 2012 to September 2013. Results: The ratio of completed certification was from 70.59% up to 97.20%, and got excellent qualified certification in 2013 Annual Cancer Care Quality Evaluation. Conclusion: The Hospital Cancer Care Quality Certification have been promoted in Taiwan since 2008, stipulate for patient-‐centered in hospital , provide interdisciplinary integration of medical services with evidence-‐medicine, safety and quality. Since cancer prevention medical institutions should be sufficient to provide cancer patients and their families cancer prevention, screening, diagnosis, treatment, hospice services, nursing care quality accounted for a very important role, and must be integrated multidisciplinary cancer care team Persistence physical and spiritual care, through objectives management and planning, can effectively improve the quality of care, achieving staff of consensus and consistency, sense of responsibility and promote patient safety and high quality management. 1854 Software Used By Brazilian Consortium Accreditation In Educational External Evaluation Carolina C. P. Guedes1, Ana Maria F. Brito* 1, Angela C. Silva2, Deise Brasil3 1 Consórcio Brasileiro de Acreditação, 2Fundação CESGRANRIO, 3Informação, Consórcio Brasileiro de Acreditação, Rio de Janeiro, Brazil Objectives: This study presents results of an evaluation that aimed to determine the degree of satisfaction of the employees of the Brazilian Accreditation Consortium CBA, with the current version of the SAVE system, which is the system used as a tool to support the evaluations performed in educational health institutions. The SAVE is used to make the schedule of ratings, select team members, registering non-‐conformities found during surveys and issue the final report of the assessments. Methods: The evaluation model was developed based on consumer-‐centric approach. To assess the level of user satisfaction were used the categories Quality in Use and Context of Use, based on the standards of the series ISO / IEC 9126 and ISO / IEC 14598, aimed at assessing the quality of software product. The vision of the user responsible for the administrative activities of registration, scheduling of evaluations and compilation of the final report, as well as two users responsible for the technical coordination of the evaluations was obtained through an interview. The vision of 43 professionals, who perform evaluations in educational and health institutions using the Save for records of findings, were collected through a questionnaire received 28 responses, which is equivalent to 65% of these users. The analysis of data collected in interviews and open questions of the questionnaire was done by recording the main lines, the information obtained from the closed questions of the questionnaire were tabulated and data concerning the characteristics of the Quality in Use category were analysed by using a Importance and Performance Matrix. Results: Study participants have a positive evaluation of the SAVE as a tool for collection, compilation and preparation of evaluation reports of education but indicated several aspects that could be improved. Strengths include: the data protection and access security, real-‐time monitoring (online) in completing the assessments, reducing time of preparing and issuing reports, the integration of the activities of the evaluation team, the quality of reports and graphs generated; ease of recording of data assessment and the possibility of consulting the Manual of Standards. Suggestions for improvement: allow online consultation to legislation; increasing field to fill the evidence and recommendations; better way of distributing passwords; allow registration of additional reviewers for assessment, the possibility of selecting the form of issuance of the final report assessment by chapter, by group of chapters or complete; enable members of the evaluation team tracking the percentage of completion of elements of the assessment; blocking the publication of the assessment chapters, when it is being used by another member of staff. Conclusion: The satisfaction of end users of a system depends on how the needs of these users are satisfied, so it is essential that the products have quality and are accompanied by their managers to ensure the continuous flow of information. As all stages of the assessment were followed by CBA´s IT, which is responsible for the SAVE system, suggestions for improvement actions and elimination of many point indicated as weak, that were listed in this study, already have been considered in the new version of SAVE that entered into operation in late 2013. 1860 How To Improve The Commitment Of Clinical Staff To Accreditation? Gilmara P. Espino* 1 1 Marketing and Communication, GPeS Comunicacao Estrategica em Saude, Sao Paulo, Brazil Objectives: To study the commitment of clinical staff according to the number of days per week that they work in the institution. Identify groups that might act as multipliers. Methods: Consolidated results from an objective questionnaire that was administered to the clinical staff of 5 major hospitals (3 in São Paulo, 1 in Rio de Janeiro and 1 in the Federal District), all accredited by the methodology of the Brazilian Accreditation System (ONA). 1075 doctors responded, with their main activities as follows: surgical centers (57%), emergency care (13%), intensive care units (10%), inpatient and outpatient clinics (9%) and others (11%). For analysis, they were divided into 2 groups: ! A, containing those who work at the institution up to 2 days a week (768) and ! B, with those attending 3 days or more a week (307). Each institution invited its own clinical staff, so that the responses reflect the perception of the professional of the hospital that invited them. Results: 77% of all those interviewed said they worked at some other accredited institution. Regarding the hospital that administered the survey to them, 53.59% in A knew that it was an accredited hospital, compared to 75.08% in B. (Of the latter, however, 47.23% were not able to say what the current level of accreditation of the hospital was). Both groups agreed equally (73.5%) that responsibility with the safety of patients lies with everyone, including non-‐care staff, caregivers and the patients themselves. They also agreed on the main advantages and disadvantages of the methodology. Most cited advantages: "well defined protocols and procedures", "all staff members learn how to do their own jobs better "and" “more committed teams". Most cited disadvantages: "Inflexible routines", "constant audits, generating excessive pressure" and "increases in the waiting times of the patients". For 22.14% of B, there were no significant disadvantages. This group prefers to be informed about the process of accreditation at the hospital by e-‐mail (34.43%), in person (17.48%) and lectures and training sessions (15.64%). For A, the preferences change to: e-‐mail (46.33%), lectures and training (14.32%), direct mail (12.41%). Other differences were: The purpose of accreditation is "to ensure the quality standards of the hospital, focusing on safety and patient care," The purpose of accreditation is "to ensure that everyone respects clear rules regarding service, routines and patterns of behaviour" "I wish to participate actively" "Accreditation has brought positive changes in my routine " "I always prefer accredited hospitals and make this clear to patients" "I prefer accredited hospitals, but this is not one of my first criteria when making choices” "I feel safe with accredited hospitals, but do not consider this relevant in my choices or my patients" “Whether a hospital is accredited does not impact my decision to refer a patient " A 82% B 87% 14.3% 8.4% 26.5% 46.5% 27% 42.2% 26% 4.8% 50.5% 57.5% 31.5% 40.4% 22.5% 5.6% Conclusion: The more frequently a doctor works at a hospital, the more likely they are to understand the institutional strategy with a view to patient safety and the greater their perception regarding the value of accreditation and commitment to it. This indicates the need for different policies for internal communication for groups A and B. Hospital managers can benefit from early identification of each group, encouraging the participation of Group A in strategic discussions on patient safety, while providing them with quality indicators that underpin perceptions about the advantages and make the disadvantages clear. Group A can be viewed strategically as the multiplier of information to Group B, significantly contributing to more rapid consolidation of safety culture at the hospital. 1936 Patient Rating Tendency And Satisfaction With Care: Do Patients’ Inherent Rating Tendencies Affect Inpatient Satisfaction With Care Scores? Patricia Francis Gerstel1, Pierre Chopard* 1, Thomas Agoritsas2, Thomas Perneger2 1 Division of Quality of Care, 2Division of Clinical Epidemiology, HUG, Geneva, Switzerland Objectives: (1) To assess the relationship between patients’ inherent Rating Tendency (RT) in a tertiary hospital and satisfaction with inpatient care and case-‐mix variables (2) To determine departmental rankings of satisfaction with care in an adjusted and non-‐adjusted model including RT scores. Methods: 4-‐6 weeks after discharge, adult patients hospitalised in the University Hospitals of Geneva (HUG) for >24 hours during one month were mailed a validated inpatient Picker questionnaire and 12 vignettes describing hypothetical scenarios to be evaluated on a scale of 1 to 7 for quality of care (1: very poor, 7: excellent). The first two scenarios described excellent and very poor quality (anchoring items) and subsequent scenarios problematic care. The patient’s RT was calculated according to the mean of the 10 non-‐anchoring items (a previously validated score in HUG). Patient satisfaction was assessed with the short Picker Patient Evaluation score (PPE-‐15). Additional variables collected were age, sex, nationality, level of education, length of stay (LOS), perceived health status, feeling sad or blue in the past 4 weeks and change of perceived health status since hospitalisation. Mean PPE-‐15 and mean RT across departments and case mix groups were computed. Differences were assessed with chi-‐squared or Kruskall-‐Wallis tests. Departments were ranked according to PPE-‐15 scores. Univariate and multivariate linear regression analyses were carried out and adjusted PPE-‐15 scores were compared across departments. Results: Of the 3261 eligible patients, 1409 patients (43.2%) answered at least 50% of the RT questions and the 50% of the PPE-‐ 15 questions and were included in the analyses. Most patients understood the task of rating the clinical scenarios and rated the difference between anchoring items on opposite ends of the scale. The difference between the anchoring items was the maximum for the majority of respondents. Factor analysis confirmed the scale as unifactorial with an average scale reliability of 81.6%. RT scores were normally distributed with a mean of 3.6 (SD 0.96). Women, younger patients and non-‐Swiss nationals gave significantly worse RT scores. Feeling sad was significantly associated with lower RT. Mean RT scores varied significantly across departments and persisted despite adjustment for age, sex, origin and sadness. RT was weakly correlated with PPE-‐15 (Spearman’s rho: -‐0.1046, p<0.001). For each one point increase in RT scores, PPE-‐15 diminished by 3.7% (95%CI 2.2–5.2%, p<0.001). Even though adjusting for RT alone did not modify departmental ranking, adjusting for RT in addition to case mix variables modified the PPE-‐15 ranking of departments (internal medicine surpassed surgery). Conclusion: Analysis of the vignettes revealed a unifactorial item (RT score) with high internal consistency. Factors associated with RT were sex, age, nationality and sadness. RT was not associated with health status and thus was not a surrogate of this, nor was it strongly correlated with satisfaction of care scores, further validating this score as an independent item. Higher RT was associated with lower PPE-‐15 scores and departmental ranking was altered in a fully adjusted (RT and case-‐mix variables) model. We believe that RT should be included in adjusted models for satisfaction scores, especially when rating tendencies differ across units evaluated. 2016 Suicide In Older People Who Are Living In Community Li-‐Bi Huang* 1, YUN-‐FANG TSAI2 1 1Department of Nursing, Chang Gung Memorial Hospital, Linkou, 21Department of Nursing, Chang Gung University, Taoyuan, Taiwan Objectives: This study aimed to explore the feelings in the presence of suicidal idea, the provoking factors of suicidal ideas, and factors for prevention of suicidal attempts in the community elderly aged 65 years or older. Methods: Thirty-‐two outpatients in one medical center in the Northern Taiwan were enrolled in the study. By using qualitative research methods and deep-‐depth interviews and data analysis method. Results: The presence of suicidal ideas in the community elderly was associated with the stressful life events such as “having physical illness”, “no reward despite hardworking for one’s whole life”, “the emotion under the impulsivity”, and “painful memory”. Negative feelings such as “loneliness”, “disrespectfulness”, “hopelessness”, “sadness”, and “lack of survival value” would increase the degree of suicidal idea in elderly. The positive factors such as “good social support”, “enriched elderly life”, “readjustment of mood”, “effective treatment”, “comfort from religion”, and “having sense of mission to family” would decrease the suicidal idea in elderly and enhance positive thoughts. Conclusion: Stressful life events and psychological factors might be incorporated into the in the assessments of suicidal ideas screening to provide early detection and effective intervention for elderly suicide, References: • Bridge, J. A., Goldstein, T. R., & Brent, D. A. (2006). Adolescent suicide and suicidal behaviour. Journal of Child Psychology and Psychiatry and Allied Disciplines, 47(3-‐4), 372－394. • Cattell, H.（2000）.Suicide in the elderly. Advances in Psychiatric, 6（1）, 102-‐108. • O’Connell, H., Chin, A. V., Cunningham, C., & Lawlor, B. A.（2004）. Recent developments: suicide in older people. British Medical Journal, 329, 895-‐9. • Paul, S.F., Yip, I.C., Helen, C., Kwan, C.W., Yeates, Conwell, & Eric, C.（2003）. A prevalence study of suicide ideation among older adults in Hong Kong SAR. International Journal of Geriatric Psychiatry, 18, 1056–1062. 2077 Knowledge, Attitudes And Practices Of Health Care Workers Towards Needle Stick Precaution At The Medical Centre In Taiwan Liu Hwa-‐Nien* 1, Hsieh Yu-‐Lin1 1 Quality Management Centre, Far Eastern Hospital, Taipei, Taiwan Objectives: Needle stick is common occupational injury in the hospital, and needles may be infected blood-‐related diseases, such as Hepatitis B, Hepatitis C, Syphilis, and Human Immunodeficiency Virus (HIV). This study investigated the knowledge, attitudes and practices of health care workers towards needle stick precaution and related factors at the medical center in Taiwan. Methods: A cross-‐sectional survey during August 2012 to December 2013 was conducted. A structure questionnaire from Huang et al. (2012) as research tool. We enrolled effective sample for 354, respond rate 98.9%. We were investigated of needle stick prevention knowledge, attitudes, and practices among new employees. We used proportion to descriptive sample characteristic and distribution, and used t-‐test to understand difference of knowledge and attitudes between with or without needle stick. Results: This study subject 92% for female, average age for 24.9 ± 4.8, approximately 70% education degree above college, average year of work experience for 3.3 ± 4.4. We found incidence of needle stick among female for 17%, male for 0% have significant difference between with or without needle stick (p<.05), and have no significant difference such as age, education, average year of work experience. We also found “process and harm of needle” have lower correctly rate about in 30%~50%, such us disinfection, and we also found with needle stick experience employee have lower score than without, especially “reward to safety procedures of employee ” and “use safe containment of sharps” have significant difference between with or without needle stick (p<.05). Conclusion: This study found lower incidence of needle stick by male, because his job environment also have lower chance of needle stick, such as: pharmacy, nuclear medicine. This study also found new employees have better knowledge of needle stick prevention, such us “use safe containment of sharps”, “recapping needles”, but in the process and harm of needle have poor knowledge. In the future, we should strengthened harm and protect of needle, to preserve safety and improve health of employees, maybe we would explore needle stick of gender differences in the next. References: 1. Huang, S.F., Su, S., Dai, Y.T. (2012). A preliminary study of needle stick and sharps injuries in doctors and nurses at a medical center in Taiwan. Journal of Nursing and Healthcare Research, 8(2), 117-‐127. 2. Hsieh, Y.U., Hwu, Y.J., Chang. T.M. (2006). An investigation of needle stick prevention knowledge, attitudes, practices and related factors among nurses. Journal of Evidence-‐Based Nursing, 2(4), 284-‐291. 2173 The Prevention Of Preventable Death And Permanent Dysfunction After Internal Bleeding Hao-‐Hsien Lee* 1 1 Surg, Chi Mei Hospital, Tainan, Taiwan Objectives: Although hypovolemic shock has been studied for decades, unrecognised internal bleeding resulting in death or permanent dysfunction still remains a problem. It comes from complicated pathophysiology which may progress with ambiguous symptoms or signs, or it occurs with a short interval after the warning symptoms or signs. Methods: This is a retrospective analysis of the preventable death or permanent dysfunction after internal bleeding from the documented malpractice verdicts of the criminal court in Taiwan from year 2000 to 2010. The clinical course, cause of death, negligent procedures, and mask factors related to pre-‐management assessment, diagnosis or treatment were analysed. Twelve cases were studied, five from emergency, seven not emergent; nine received autopsy, two had definite pathology after surgery, one blood-‐ type mismatching confirmed by all families’ blood test. Eight abdominal lesions include: one liver, one kidney, one biliary tract, two uteri, one aorta, one femoral artery, and one pelvic floor. Three thoracic lesions include: one intercostal artery rupture with extra-‐pleural bleeding, thus, no drainage from chest tube, one subclavian vessel rupture after non-‐penetrating injury, and one tension hemopneumothorax aggravated by general anaesthesia for orthopaedic surgery. One blood-‐type mismatching results in acute renal failure and systemic DIC. Results: The negligent assessments or managements were: ten cases without adequate managements for pre-‐shock or shock status, one missed blood typing without considering families’ suggestion and ignored hemoglobinuria, one iatrogenic trocar injury to aorta during laparoscopic surgery, two technique failures to stop bleeding: one from renal laceration receiving not deep enough suture repair and another tie loosening of femoral artery stump, one improper laparoscopic cholecystectomy instead of open procedure as being the third time abdominal surgery, one no definite thoracic drainage after lung parenchyma injury, thus intubation’s general anaesthesia induced disastrous tension hemopneumothorax. The mask factor is used to signal errors that were done by physicians. Such errors include the following: eight cases of pre-‐shock missed as irritability caused by pain or anxiety, one with haemoglobin level 10.5 g/dl-‐ no definite hemodilution 40 minutes after surgery, one missed as alcoholic effect. Nine cases had no profuse drainage from the tube or wound, one followed the families’ wrong treatment plan thus delayed Caesarean section makes atonic uterus, one believed laboratory data without considering family suggestion in blood-‐ type mismatching, one minimal pulmonary laceration resulting in disastrous tension hemopneumothorax after intubation’s general anaesthesia, one pointed to the new operation skill in difficult anatomy. The interval between negligent symptoms or signs and irreversible crises were: Group A-‐ active bleeding without management: 2 hours 1 minutes ± 53 minutes (range: 40 min. to 3hr.25 min. N= 8), Group B-‐ continuous bleeding with biological tamponade but no adequate management: 18 hours 18 minutes ± 4 hours 30 minutes (range: 12 to 22 hr. N= 3). The mismatched case received 5500 ml AB type blood instead of O type during the 5 days period before severe DIC attacked. Conclusion: Internal bleeding from thoracic or abdominal visceral organs may be a simple but sometimes difficult problem acknowledge the pathophysiology and timing factors may prevent such disasters. 2260 Student Lead Quality Improvement Projects Lead To Improved Patient Care In A Real World Setting Sergej Cicovic* 1, Nikola Lilic1 1 Auckland City Hospital, Auckland, New Zealand Objectives: Background: Recent educational initiatives by both the World Health Organization (WHO) and the American Association of Medical Colleges have endorsed integrating teaching of patient safety and Quality Improvement (QI) to medical students. Furthermore, there has been greater encouragement of student lead QI projects as a way of real world teaching and improved outcomes to patient care. Our study has focussed on QI projects in the Obstetrics and Gynaecology Department of a large tertiary New Zealand hospital. The current accepted worldwide best practice for Lower Segment Caesarean Section (LSCS) at full dilatation is that a consultant/attending obstetrician must be present due to the higher risk of complications to the mother and foetus. Objective: To assess the impact that a student lead QI project can have on improving adherence to quality standards and thus improving patient care. Methods: An audit of consultant presence during full dilatation LSCS at a large tertiary obstetric unit in New Zealand was undertaken by medical students from the University of Auckland, School of Medicine. Following an initial audit, a subsequent intervention was performed where the data was presented to the Hospital’s Obstetrics and Gynaecology Department. Departmental meetings were then held to reiterate the current best practice and the hospital’s protocol. Barriers relating to why the protocol was not being followed were also discussed. A follow up audit was performed 6 months later by another group of medical students. Results: The initial audit found that 67% of full dilatation LSCS had a consultant present in theatre at time of delivery. Following the interventions stated, the second audit found that consultant presence had increased to 87%. The increase in consultant presence between the two audits was statistically significant (p = <0.01). Conclusion: We have shown that medical student QI projects can have a large role to play in showing deficiencies in medical practice and can lead to interventions that increase adherence to quality standards. This not only serves educational purposes but also improves medical care of patients. 2293 The Experience Of Effectiveness Of Individualised Health Education By Pharmacists On Community Pharmaceutical Care Hsin-‐Ling Pang* 1, P-‐Y Lee1, Y-‐L Chen2 1 Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, 2Department of Pharmacy, Kaohsiung First Pharmacist Association, Kaohsiung, Taiwan Objectives: Medication safety is essential concerning quality of health care. Doctor shopping behaviours, polypharmacy, and self-‐ medication are harmful to health and cause healthcare waste. This survey aimed to investigate current medication behaviour of patients in Taiwan by questionnaires and educated them to acquire appropriate knowledge about drugs. To co-‐operate with the plan of Department of Health, “the correct medication education resource centre” has been set up in Kaohsiung County in order to combine with local medical resources and teaching activities for correct medication. In addition, revitalising the community pharmacy services and increasing public knowledge of the correct medication may strengthen the public security division of labour and assist local health agencies or school educational activities to promote the correct medication. Methods: This was a nine-‐month study, starting from Mar.01, 2013 to Nov.30, 2013. In total 600 participants were recruited from Kaohsiung County. Medication cognition questionnaires in the health education seminars include surveys of people’s behaviours on using drugs, people’s knowledge about medication, and health education satisfaction rate. Based on the analysis of the questionnaires, we will be able to advocate patient medication education in the future and establish appropriate indicators, which can be used for evaluating performance, with local characteristics. Results: Five hundred eighty two of the drug cognition questionnaires were returned, with a return rate of 97%. The results of this survey showed: Those who take western medicine, Chinese medicine or health care products within the past month were 62.1%, 30.8%, 43.8% respectively, and those who take these three kinds of medical products simultaneously within one month are up to 34.1%. Second, reasons for people to dispose of used drugs: mainly for drug expiration and the other reasons are people forget to take medicine or they don’t want to. Third, items which people want to get information about the medicines are the indications of drugs, drug usage and drug effects, which are ranked as the top three. Fourth, the drug-‐related information people require are mostly from pharmacists, followed by physicians, description on the drug bag or packaging, nurses or other else. Finally, satisfaction survey results indicate that 94.6 percent of respondents are satisfied or above according to the propaganda activities of the overall satisfaction. The results of this study also suggest that the expected target has achieved concerning people’s knowledge of the useful content in the propaganda and the teaching skills of lecturers. Moreover, a variety of creative teaching and learning activities, such as medication safety led by the singing team or a drama involved with drug safety situation were designed so that people were truly impressed and could really perform the drug safety through those creative teachings. Conclusion: During the study period, pharmacists were encouraged to develop diversified correct medication health education model. By the interaction between pharmacists and participants, participants will gain the medication safety information properly and continue self-‐monitoring medication knowledge. It will enhance medical quality and reduce unnecessary medication expenses. Pharmacists should provide appropriate medication information for consultation. What could be done in the future are as follows: To educate people how to use medication use properly, and make good use of healthcare information system, establish specific indicators to evaluate the effects. 2306 "Institutional Training" Sandra C. Da Silva* 1, Victor M. Ribeiro1, Eduardo Gonçalves1, Elaine Ambrosio1 1 Quality, Sociedade Beneficente de Senhoras Hospital Sírio-‐Libanês, São Paulo, Brazil Objectives: Share the different methodologies used in training, to employee qualification and involvement in the management system of quality and patient safety. Methods: To operationalise Institutional trainings the various forms of active learning methodologies were selected in order of having the highest rate of adherence and absorption of content taught to all employees. For the training focused on ISO 14001 (Environmental Management) and OHSAS 18001 (Occupational Health and Safety) norms, participants were divided into teams identified by colours. A structure with screen, joystick and colourful pushbuttons was assembled, matching the colours of teams. Questions related to the standards were answered through the joysticks and pushbuttons. The team earned points according to the percentage of correct answers. For trainings focusing on quality processes and patient safety, the game was held in the Naval Battle format, in which assembled a structure with large screen projection of the issues and key pad for participants to answer. Employees were divided into two teams and whoever answered correctly and faster scored points. Other format was a Bingo. All participants received a card, a sentence with a gap was projected and those who contained the corresponding complement marked it on the card. Employees who marked four corners, horizontal line or the full chart earned a gift. The latest initiative was a word search dynamic. Employees were divided into four groups and tried in turns to guess the letters in a sentence. When there were enough letters the group could try to complete the sentence. The letters and phrases scored up, and the phrases were entitled to a higher score. Results: The results are demonstrated in the table below: Table 1: Overview of the Trainings Adherence. Hospital Sírio Libanês 2013 ISO 14001 / OHSAS 18001 92,17% Quality Standards I 89,84% Quality Standards II 90,56% Quality Standards III 89,35% To measure the success of formats, a survey was conducted via the Intranet in the week of 13/01 to 01/17 2014, whose results showed that 93% of employees responded that they considered important and innovative Training Methodologies. Conclusion: The results show that the use of interactive and unorthodox training methodologies positively influences the adherence of employees to the proposed dynamics. Furthermore, there was wide acceptance of the dynamics from those who responded to the proposed survey. New studies in order to maintain innovation in training techniques should be considered for 2014. 2366 Alcohol Use Prevention Project For Adolescents Aline F. Pedrazzi* 1, Priscila D. Gonçalves1, Arthur G. Andrade1, Bettina Grajcer2 1 Grupo Interdisciplinar de Estudos de Alcool e Drogas, Instituto de Psiquiatria do Hospital das Clínicas, 2Lynx Consultoria social and environmental projects, Sao Paulo, Brazil Objectives: To encourage and support the implementation of preventive measures in the São Paulo state school network to inhibit the consumption of alcohol before the age of 18 years. Methods: A Pilot Project was implemented for the Prevention of Alcohol Consumption in Adolescence. The project directed principally at 28 schools in 3 Education Districts. Because it used an innovative strategy and method, the option of restricting the pilot project to 28 schools was aimed at testing, evaluating and refining the method and instruments, which would then be extended to the São Public school network. The actions carried out were directed at the group of schools with teachers, mediators, students and community members. This project was designed to sensitize the teaching staff, to promote parent meetings, preventive cultural interventions (workshops involved the formation of 1 group of reference students plus 1 teacher) and the use of relationship networks. The project used theoretical supports and practical proposals that were included in a Guide that was delivered to the teachers. The guide provided teachers with background information upon which to base their presentations and discussions of the topics. Diverse practical activities (practical module) were also proposed containing recommendations for the teacher in conducting the workshops with the students, step by step explanations, and teaching materials, including the cards necessary for the activities and dynamics. The teachers also received a DVD containing 10 interviews with specialists. This audio-‐visual material complemented both the practical and theoretical parts of the Guide. Results: At the beginning of the project the teachers and administrators stated that 84% considered it “important” or “very important” to address the subject at school; 85% did not feel qualified to address the subject at school; 92% were “interested” or “very interested” in receiving information about: the effects of alcohol on the body, the risks of consuming alcohol during adolescence and how to address this subject with the students. Six workshops were held for each reference group. The workshops were divided into 2 parts: a. Training in alcohol and prevention through entertaining and fun educational materials developed for this purpose. b. Training for conducting preventive cultural interventions aimed at other young people. The interventions developed included: 16 “alcohol free parties”, 7 videos, 5 photography exhibitions, 3 “cineparties”, 3 visual art shows, 2 music festivals, 2 fanzines and 1 sports tournament. A total of 156 workshops were held in 28 schools, with 14 thousand students participating in the preventive interventions (an average of 500 students per school). A total of 1,731 teachers and school principals were reached; there were 95 participants in the parents' meetings. Conclusion: The positive evaluation of the pilot project by the students (98.9% “Excellent” and “Good”) showed that the method was adequate for implanting the alcohol consumption prevention measures in the schools. The students showed great involvement, planning and producing one or more interventions per school. The peer education proposal not only showed that the students are capable of developing interventions, but also that this is an effective methodology, ensuring young people's interest in the project. The pilot project reached level 3 according to the Kirkpatrick1 impact evaluation model. Thus, the conclusion is that the methodology employed was completely adequate for the purpose of the project and for the target public. References: Kirkpatrick, D.L. Evaluation of training. In: CRAIG, R.L. Training and development handbook.2ed.New York: Mc Graw-‐Hill, 1976. 2469 A Cohort Study On A Comprehensive Training Program For Enhancing Staff Competence In Prevention Of Unplanned Extubation In Ventilator Ward WFW Tsang* 1, WHJ Law1, CH Chan2, SH Leung1 1 Medical Specialty, 2Intensive Care Unit, Queen Elizabeth Hospital, Hong Kong, China Objectives: Queen Elizabeth Hospital is one of the major acute hospitals in Hong Kong. It receives lots of critically ill patients. Patients with mechanical ventilator would be admitted into the Intensive Care Unit according to the triage system. Patients who could not be admitted into the Intensive Care Unit would be admitted into the Ventilator Ward. The incidence of unplanned extubation which included self-‐extubation and accidental extubation was common in related area worldwide. Complications from unplanned extubation such as ventilator-‐associated pneumonia, which significant increased the mortality and morbidity of patients and the adverse event rate was range up to 28%. Staff competence played an important role in prevention of unplanned extubation. A comprehensive program was designed to enhance the staff competence in prevention of the event in the Ventilator ward. The aim of the study is to investigate the staff competence before and after the comprehensive training program in prevention of unplanned extubation. The training program included physical restraint, sedation protocol and the management of difficult airway towards unplanned extubation rate in the ventilator ward. Methods: Three half-‐day trainings which included lectures, video and return demonstration were conducted by the Quality and Safety Team members of Ventilator Ward in March 2013. A pre and post training quiz was given to the nursing staff. The program was consisted of knowledge of physical restraint and application techniques, revised nurse-‐led sedation protocol, and recognition of difficult airway. The target participants were staff of the Ventilator Ward. Data was taken from the pre-‐test and post-‐test of the program and score was compared. Paired t-‐test was used to analyse the data. Results: Pre-‐test and post-‐test quiz were given to all participants and the return rate was 100%. The score reflected the staff improvement of competence in the three aspects area which could prevent the risk of unplanned extubation. The rate of unplanned extubation would be compared. In reviewing the two tests, the score was found significantly increased after the training. Paired t-‐test analysis was performed and the mean score of pre-‐test was 57.31 (N=52, SD 24.54) while that of post-‐test was 92.5 (N=52, SD=12.89). The mean score was increased after the training is 35.19 (95% confidence interval 28.07 -‐ 42.31; P< 0.0001). After the training, the rate of unplanned extubation was compared. The unplanned extubation rate decreased from 8.33 % (24 episodes in 180 days) before to 4.35% (11 episodes in 180 days). The 1000 bed day occupancy was significant dropped from 17.8 to 6.8. Conclusion: Unplanned extubation could result in several life-‐threatening complications. Good nursing practice care to those patients was in no doubt utmost important especially in the management of physical restraints, titration of sedation and the management of difficult airway. A set of training on these areas could enhance the competence and alertness of unplanned extubation. Furthermore, the rate of re-‐intubation, length of stay and 1000 bed day occupancy of those unplanned extubation patients reduced significantly after the educational program. References: 1. Zwillich CW, Pierson DJ, Creagh CE, et al: Complication of assisted ventilation: A prospective study of 354 consecutive episodes. Am J Med 1974; 57:161-‐170 2. Coppolo DP, May JJ: Unplanned extubations: A 12 month experience. Chest 1990; 98:165-‐169 3. Whelan J, Simpson SQ, Levy H: Unplanned extubation. Predictors of successful termination of mechanical ventilatory support. Chest 1994; 105:1808-‐1812 2483 Developing Competencies To Improve Quality: Experience With Undergraduate Nursing Students In Applying PDCA Cycle And Using It In Care Management Elena Bohomol1, Magaly Reichert1, Isabel Cristina K. O. Cunha1, Lúcia Marta G. Silva* 1 1 Administração e Saúde Coletiva, Escola Paulista de Enfermagem UNIFESP, São Paulo, Brazil Objectives: To present an educational program for training undergraduate nursing students to help improve the health system in which they participate, and demonstrate the efficacy of undergraduate nursing students working as trainees at care units in applying the Plan-‐Do-‐Check-‐Act (PDCA) cycle. Methods: During the 2013 school year, 68 fourth-‐year undergraduate nursing students at Escola Paulista de Enfermagem da Universidade Federal de São Paulo applied the PDCA cycle in patient care units in different specialties during 160 hours (27 working days) of a nursing administration training program. First, students were exposed to 4 hours of a theory class in the discipline of nursing administration. Each student completed the class load in the care unit at a teaching hospital, developed actions for care management that emphasised the proposed exercise using quality tools to identify problems in units, and applied all PDCA steps. To reinforce PDCA cycle steps, three sessions of 3 hours each were conducted during practice activities. Each session involved specific tasks to be done by students and the preparation of reports describing the progress achieved. Professors supervised activities in the field, along with the responsible unit nurses. Pedagogical focus was on exercising the educational dimension and management of the nurse’s working process. Results: Of 68 students who applied the PDCA cycle, 53 (77.9%) completed the reported to be analysed. Of this total, 46 (86.8%) identified, as proposed in the theory-‐based meetings, one problem in the unit by using an in-‐house institutional database, at brainstorming sessions, or by direct observation of processes; this was in addition to using checklist questionnaires completed by the unit team. Seven students (13.2%) were chosen to select the problem on the basis of a suggestion made by the responsible nurse on the unit. Prevalent care processes were manipulation and care of short-‐ term venous devices, the use of individual protective equipment, adherence to fall prevention measures, knowledge of cardiopulmonary resuscitation manoeuvres, and recording of fluid intake in patients with diet restriction. In phase D, all students conducted education actions, such as oral presentations and discussion of the subject with the unit nursing team (64.2%), distribution of educational material (28.3%), or simulation (3.8%). In phase C, trainees conducted reactive assessment (64.2%), assessment of team knowledge on the approached subject (28.3%), and “in loco” assessment of the effect of the intervention on daily working routines (28.3%). The proposition for phase A would be to verify the need to restart the cycle, reported by 32.1% of students, and propose new strategies for needs. Conclusion: The education of future nurses must prepare them not only to deliver quality care for patients but also to reflect about the context in which they act. Nurses need to define a problem, identify involved agents, use analysing tools, determine actions that need to be implemented for corrections, and evaluate interventions. This study showed that the majority of fourth-‐year undergraduate nursing students were able to conduct the activity with success. The study of phase A of the PDCA cycle requires further reflection. 1335 The Global Comparators Project: Hospital Mortality In 5 Countries Milagros Ruiz1, Alex Bottle1, Paul Aylin* 1 1 Dr Foster Unit at Imperial College London, Department of Primary Care and Public Health, London, United Kingdom Objectives: Previous studies have identified a weekend effect on mortality in both US and UK hospitals1,2,3, with mortality tending to be higher at the weekend compared with weekdays. We use a standardised international data set to examine mortality outcomes in 5 countries. We examine emergency admissions and admissions for elective surgical procedures, and compare crude mortality rates and adjusted odds of death by day of the week. Methods: We use the international standardised data set from the Global Comparators Project4,5 which consists of administrative data from selected hospitals in 8 countries. We examine in-‐hospital deaths for emergency admissions and elective surgical procedures for 5 of the participating countries (England, Australia, USA, Netherlands and Italy) between 2009 and 2012. Adjusted odds of death are calculated by using logistic regression and adjusting for age, gender, year of admission, comorbidity score, quintile risk, and day of the week and compared to a Monday admission. Results: We examined a total of 3,201,894 hospital records from 40 hospitals. Adjusted odds of death were significantly higher for weekend emergency admissions for English (OR 1.08), US (OR 1.13) and Dutch (OR 1.19) hospitals (p<0.01); Italian hospitals show increased odds of death for Sunday only (OR 1.10, p<0.05). Australian hospitals showed no variation in adjusted mortality throughout the week for emergency admissions. For elective surgical procedures taking place on a weekend the adjusted odds of death was higher for all countries; it varied from 1.41 on a Saturday for English hospitals (p<0.05) up to 6.96 on a Sunday for Italian hospitals (p<0.0001). Conclusion: By using the standardised data set from the Global Comparators project, we were able to make direct comparison of mortality outcomes between countries. Our study shows inter-‐country differences in crude and adjusted mortality, by day of emergency admission and by day of elective surgical procedure. References: 1. Aylin P; Alexandrescu R; Jen MH; Mayer EK; Bottle A. BMJ 2013;346:f2424 2. Aylin P; Yunus A; Bottle A; Bell D. Qual Saf Health Care 2010;19:213-‐217 3. Bell CM; Redelmeier DA. N Engl J Med. 2001 Aug 30;345(9):663-‐8. 4. Dr Foster Intelligence. http://drfosterintelligence.co.uk/global-‐comparators/ 5. Global Comparators Project: International Comparison of Hospital Outcomes Using Administrative Data. Bottle A.; Middleton S.; Kalkman C.J.; Livingston E.H; Aylin P. 2013, Health Services Research. doi:10.111/1475-‐6773.12074 1615 Investigating Adverse Event Free Admissions In Medicare Inpatients As A Measure Of Patient Safety Alice King* 1, Alex Bottle1, Paul Aylin1 1 Imperial College London, London, United Kingdom Objectives: Preventable complications and adverse events could be further reduced in acute care to improve patient safety. These are challenging to measure as patients may experience more than one event and aggregate measures are known to be difficult to accurately interpret. Furthermore little is known about proportions of patients discharged without experiencing any potentially preventable adverse events which is an important goal of patient safety. Here we investigate adverse event free admissions as a measure to improve patient safety. Methods: Medicare Inpatient datasets 2009-‐2011 with corresponding denominator files were processed according to standard criteria. Events were defined as: 1) 2) 3) 4) 5) Death within 30 days (excluding high risk mortality groups) Unplanned Re-‐admissions within 30 days Long Length of Stay (for diagnostic group) Healthcare Acquired Infections Healthcare Acquired Conditions not present on admission. These were all defined based on Medicare published validated criteria. Event free admissions were then defined as those that did not experience any of these events. Results: Out of 23,991,193 admissions, 51.7% were adverse event free. Overall; 4.6% died within 30 days, 16.6% experienced unplanned readmission, 12% had long LOS, 26.8% had infection not present on admission and 16% experienced healthcare acquired conditions. Of the admissions with events 9.6% were deaths, 34.4% had unplanned readmissions, 24.6% experienced a long length of stay for diagnostic group, 55.5% had healthcare acquired infections and 33.2% were healthcare acquired conditions. 43.7% of events occurred as multiple events with 13.4% experiencing 3 or more events. Conclusion: Just over 50% of Medicare admissions 2009-‐2011 were adverse event free admissions. Multiple complications and events are common. These may indicate high risk patients who need to be identified for intensive management or they may indicate areas where improvements in one area may have consequences for other events and overall patient care. Further work is needed to investigate (and increase) the proportion of patients who have event free admissions. Disclosure of Interest: A. King Grant / Research support from: The Dr Foster Unit at Imperial College London is funded by a grant from Dr Foster Intelligence (an independent healthcare information company and joint venture with the Information Centre of the NHS). The data was acquired by Dr Foster Intelligence. The funders had no role in the study design and the collection, analysis, and interpretation of data, the writing of the abstract, or the decision to submit it for the conference., A. Bottle Grant / Research support from: The Dr Foster Unit at Imperial College London is funded by a grant from Dr Foster Intelligence (an independent healthcare information company and joint venture with the Information Centre of the NHS). The data was acquired by Dr Foster Intelligence. The funders had no role in the study design and the collection, analysis, and interpretation of data, the writing of the abstract, or the decision to submit it for the conference., P. Aylin Grant / Research support from: The Dr Foster Unit at Imperial College London is funded by a grant from Dr Foster Intelligence (an independent healthcare information company and joint venture with the Information Centre of the NHS). The data was acquired by Dr Foster Intelligence. The funders had no role in the study design and the collection, analysis, and interpretation of data, the writing of the abstract, or the decision to submit it for the conference. 1770 Performance Evaluation Form For Teachers Of CBA: A Study Of Usefulness, Suitability And Accuracy Carolina C. P. Guedes1, Rima Farah* 2, Lucí Hildenbrand3 1 Academic Researcher , 2Project Adviser for Co-‐ordination of Education , Consórcio Brasileiro de Acreditação, 3Fundação Cesgranrio, Rio de Janeiro, Brazil Objectives: To evaluate the Form of Performance Evaluation named Teacher Evaluation, used by the Education Coordination of Consórcio Brasileiro de Acreditação (CEDUC/CBA), as the patterns of the categories of usefulness, suitability and accuracy, established by the Joint Committee for Educational Evaluation. Methods: The methodology was set in accordance to the objective of the study and approach focused on consumers. From the set of selected categories were chosen and tailored nine standards to subsidise the evaluation: attention to the teacher, notified purposes, explicating knowledge, attitudes and accomplishments, relevant information, processes and significant products (usefulness); nature of the information (suitability); valid information, reliable information and communication (accuracy). Based on the standards it was developed and validated a 17 items questionnaire. The validation process of the questionnaire comprised the technical and content validations performed by two Evaluation’s experts. All the 32 teachers in evaluation of CEDUC were invited to take the evaluation of the form. Results: From the 32 teachers, only 17 presented their judgments. In relation to the general aspects of the form, 11 of the answerers stated that the form facilitates the expression of their opinions about both personal and normative aspects. With regard to the technical aspects, 13 reported be easy to express their opinions through the form. Equal number of answerers stated that the form displays its purpose clearly and also helps the teacher to identify necessity of training and qualification. All of the answerers considered that was important to know the purpose of the evaluation. For 12 of them the evaluation results are consistent with the purpose of the form. The total of professionals who declared they did not receive training to use the form was seven; three said they had doubts as to fill it out. Most of the answers highlighted that the enunciation of each of the personal aspect is clear: Attitude and Responsibility were evaluated positively by 13 of the answerers; Presentation, Punctuality and Relationship with the external institution for 14, and Relationship with the CBA for 15. Regarding to the technical aspects, most of the professionals attributed clearness the presentation of assessed items; The Knowledge of the Manual and Applicable Standards was judged positively by 13 of them; Relationship between the Chapters, Standards and Elements of Measurement front the Findings by 14, as well as the Aspects of Preparation and Application of Questions relating to Chapters/Standards/Elements of Measurement and, Selecting and Conducting of Trackers Indicated by the Leader. The Capacity of Planning and Performing Scheduled Activities also had satisfactory judgment (15). The lowest level of agreement (10) was assigned to the item regarding the Ability to Deal with Conflict Situations not envisaged during the Evaluation. Conclusion: The analysis of the results demonstrated that, in the category usefulness of the five studied standards, only the standard Relevant Information has been met. Three other standards of category were partially met and one not met. In the category suitability the studied standard was partially met. And, in the category accuracy, the standard Communication was met, while other two were, respectively, partially met and not met. 1889 Culture Of Patient Safety In An Unit Oncology Of Hospital Accredited: Perception Of The Professional Nurse Carolina C. P. Guedes* 1, Simone D. A. Carrera2, Beatriz G. C. Aguiar3 1 Pesquisa Acadêmica, Consórcio Brasileiro de Acreditação, 2Instituto Nacional do Câncer, 3Escola de Enfermagem Alfredo Pinto/ Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil Objectives: Discuss the perception of nurses about the safety culture in the process of patient safety established in an oncology hospital accredited. Methods: This was a qualitative and quantitative study. The results of a Master thesis performed between 2012 to 2013 in one of the hospitals of a Federal Public Institution Oncology in the city of Rio de Janeiro, reference in the diagnosis and treatment of cancer in Brazil, accredited by the Joint Commission International (JCI). The study included 47 nursing care, most of whom works in the unit less than 5 years. The questionnaire of Agency for Healthcare Research and Quality (AHRQ) was applied to measure the evaluation culture of patient safety. The questionnaire of AHRQ defines as patient safety the actions to avoid or prevent damage or adverse to the patient, resulting in the delivery of health services process effects. It is a multidimensional questionnaire with 12 dimensions, composed of 42 items, which are presented in the form of Likert Scale, graded into five levels, ranging from strongly disagree or never (1) until strongly agree or always (5). The focus for this study focused on the dimensions: ! ! ! ! ! 2 -‐ expectations and actions promoting safety of supervisors and managers, 3 -‐ organisational Learning -‐ continuous improvement, 4 -‐ support for the management of patient safety, 5 -‐ general perceptions of patient safety, 6 -‐ feedback and communication about error and 12-‐Nonpunitive Answers to errors: For analysis of the questionnaire responses, were considered positive results the reach of the average above 75% and thus classified as a strong dimension of Safety Culture analysed. The results mean below 50% were considered critical. Between 50% and 75%, stands out as not problematic area of safety culture. Results: Data from 12 dimensions, 8 had response rates below 50%, thus characterising a culture of safety perceived by nurses as critical in the study unit, and 4 dimensions lies in the percentages between 50% and 75%, there being no perceived by nurses as excellent dimension. Promptly, the focus of this study have dimensions that approximately 33% do not identify who receive feedback on the changes implemented as a result of reported events and also, information about errors that occur in the unit. But, 61% identify that there is a discussion about ways to prevent errors from occurring again. 37% of respondents identified that there is involved in management actions and prioritise patient safety in the unit. And 57% indicates that the supervisor praises and becomes partner in actions taken and problems encountered. More than 60% who carry out actions to improve safety and evaluate its effectiveness. However, 30% of respondents consider that their mistakes can be used against them and the same percentage think that when an event is reported, it appears that the person is annotated and not the problem. Accordingly, 57% identify that people have fear that their errors are entered in their functional forms. Conclusion: The perception of the professional nurse on the dimensions of safety culture highlighted in this study shows that the unit develops actions for patient safety but there is a point of weakness that need to be better identified. It is worth noting that a culture takes time and dedication of managers to mature and attain its effectiveness in relationships. 1971 Innovative Strategies For Continuing Education In UniMed Paulistana Juliana G. Herculian1, Leandro D. Pereira2, Luciane M. Torrano* 3 1 Continuing Education, Unimed Paulistana, São Paulo, 2Continuing Education, UniMed Paulistana, Guarulhos, 3Quality Manager, Continuing Education and Protocols of UniMed Paulistana, Unimed Paulistana, Campinas, Brazil Objectives: The aim of this paper is to describe the new work methodology of the Continuing Education Service of UniMed Paulistana. Methods: The methodology previously used was based on employees’ training within an auditorium. These trainings were grounded in the needs indicated by the division manager. There were indicators such as: man/hour and training adherence and effectiveness. Throughout the training process, only the division manager was involved, which it was something that evidently was not effective, since there was no staff involvement, causing a negative impact in the context of learning and applicability of content. Such a strategy leads to biased and prejudiced opinions that can create a real barrier to communication and learning (Carrasco, 2001). Upon reflection, it was realised the need to change the methodology of training/institutional education in order to stimulate the employees and make them grasp the institutional information. For this, we started training based on Andragogy, which according to Carrasco MC (2001) is defined as the art of teaching adults, identified as a new science that makes people see adult teaching in a special and planned way. To meet this new challenge the sector of Continuing Education needed to break paradigms in order to incorporate the Andragogy methodology, where the employee ceases to be a spectator to become protagonists of their own development. The Continuing Education service stopped acting randomly and started to work focused on issues related to quality and safety in patient care. Results: One of the training experiments was focused in the drug chain using the insulin syringe to check the following issues: 1. Aspiration volume in odd units, 2. Full volume permission in the administration of subcutaneous medication, 3. Areas of subcutaneous application. The reviewers who answered the questions properly were awarded a medal and the employees who answered wrongly were given training right away. In another case, employees were invited to participate, by sharing their opinion of the construction of a healthcare practice for a new methodology to be implemented, which required the execution of a pilot training program. This is in accordance with Carrasco (2001) that the "adult needs to learn from their experiences, realising and systematising their knowledge”. Conclusion: With the implementation of this new working methodology the teacher becomes a mediator, being an effective communicator, which enables greater employee’s involvement and satisfaction, turning them more confident within their activities, contributing to a greater interactivity with the activities involved in the workplace. 1228 Reliability And Validity Of The Brazilian Version Of The Hospital Survey On Patient Safety Culture Claudia T. Reis* 1, Josué Laguardia2, Mônica Martins1 1 National School of Public Health, 22Institute of Communication and Scientific and Technological Information in Health, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil Objectives: Patient safety culture has been receiving increasing attention in the field of health organisations. Health care is increasingly complex, raising the potential for incidents, mistakes or failures, particularly in hospitals. A stronger safety culture in hospitals emerge as one of the essential requirements to improve the quality of health care. Assessing the status of safety culture in hospitals allows one to identify and manage prospectively issues which are relevant to safety in work routines. The aim of this study was to evaluate the reliable and validity of the Brazilian version of the Hospital Survey on Patient Safety Culture (HSOPSC) -‐ assessment instrument of the culture characteristics of patient’s safety in hospitals -‐ to the Portuguese language and Brazilian context. Methods: The reliability analysis of the instrument was performed by analysing the internal consistency of the dimensions through the Cronbach alpha coefficient. The construct validity was performed by Confirmatory and Exploratory Factor Analysis. The sample consisted of 322 professionals working in two acute care hospitals. The application of the instrument occurred between March and May 2012. Results: The HSOPSC version adapted to the Portuguese language showed overall Cronbach's alpha of 0.91. The Confirmatory Factor Analysis did not confirm the 12-‐factor dimensional structure as in the original model in the studied sample. After the exclusion of 4 items, the Exploratory Factor Analysis resulted in rates of appropriate settings for a model with 10 factors. Conclusion: The Brazilian version of HSOPSC was reliable and valid in the sample used in this study. It is necessary that the Brazilian version of the Hospital Survey on Patient Safety Culture to be tested in other samples in Brazil in order to confirm its validity and reliability, evaluated in this study. Disclosure of Interest: C. Reis Grant/Research support from: National Counsel of Technological and Scientific Development, Brazil, J. Laguardia Grant/Research support from: National Counsel of Technological and Scientific Development, Brazil, M. Martins Grant/ Research support from: National Counsel of Technological and Scientific Development, Brazil 1232 Maximise The Societal Impact Across Various Socio-‐Economic Classes In The Developing World By Expanding A High Quality Lab-‐Testing Network Resulting In Ease-‐Of-‐Access Sohail Habib* 1, Sohail Baloch2, Taha Khan3 1 Professional Services, 2Clinical Laboratory, 3Management Engineering, Aga Khan University Hospital, Karachi, Pakistan Objectives: The Aga Khan University Hospital (AKUH), Karachi, Pakistan, the only Joint Commission accredited hospital in the country, is committed to providing exemplary healthcare. It has been present in the diagnostic market for 28 years providing high quality Lab Testing facilities to millions across Pakistan with reliability and precision through its Outreach Program. The objectives of this study are to explore and develop strategies for Lab Expansion to maximise societal impact across socio-‐economic classes, which also provide ease-‐of-‐access. This, in turn, requires a resource plan coupled with innovative strategies to meet customer needs with minimum resources so as to make these services highly accessible for those who cannot afford them, thereby contributing to the overall societal uplift. Methods: The hospital leadership constituted a committee comprising of all stakeholders to develop a Lab Strategic Plan (2014-‐18) capitalising on existing strengths and carrying out both environmental and internal analyses. The committee considered national macro-‐economic indicators, global outlook and market factors using “PEST Multi-‐Dimensional Analysis” (PEST=Political, Economical, Social and Technological), SWOT Analysis (SWOT=Strengths, Weaknesses, Opportunities, Threats) and Porter’s 5-‐Forces Model. The plan has been based on current geographical presence and gaps identified based on SEC-‐ Study (Socio-‐Economic Classes) and Rural-‐Urban population balance. Results: AKUH is strongly placed to pursue Lab expansion using innovative strategies to serve a large market niche. The niche here is a scientific evaluation of its existing penetration and identifying the gaps to fill. The expansion plan has been developed catering to all critical factors and the deployment has been designed to optimise the societal impact particularly in those areas which have no quality testing facilities available. This will be achieved by the further establishment over the next five years of 157 additional specimen collection centres (current 206 centres) and 3 additional STAT Labs (current 4 STAT labs) plus the added strategy of having 4 Regional Labs (currently we have none) to enable further testing on location and resulting in faster turnaround time and lower costs. AKUH has 16% market share (5.2 million tests) of an estimated outreach market size of 31.4 million Lab Tests in the whole of Pakistan. However, when this market share is drilled down to a Provincial level, the scenario shows highly different concentrations as shown in the table below: Province Population Sindh Punjab Balochistan KPK Total 45,000,000 100,800,000 9,000,000 25,200,000 180,000,00 Population (%) of Total 25% 56% 5% 14% 100% Lab Test Market Size (millions) 8 18 1.4 4 31.4 AKUH share of Lab Test Market (millions/%) 4 (50%) 1.08 (6%) .01 (7%) 0.12 (3%) 5.21 (16%) Based on this, the strategic plan envisages a growth in Lab presence from a current total of 5 million tests/year to 8 million tests/year over a 5 year period. This will allow us to give access to high quality lab services to 33% of the market as compared to 16% today. Conclusion: We at AKUH strongly believe that our innovative approach and strategic model can be replicated in under-‐privileged geographical locations around the globe. The suggested model is self-‐sustaining and economically viable. Furthermore, it incorporates the revenue model and resource optimisation model to eradicate unnecessary costs and allows us to deliver high quality healthcare facilities at the lowest possible cost base and divert the maximum savings to the AKUH patient welfare program. 1246 Performance Indicators Used Internationally To Report Publicly On Healthcare Organisations And Local Health Systems Peter D. Hibbert1, Natalie Hannaford2, Jennifer Plumb1, Jeffrey Braithwaite* 1 1 Australian Institute of Health Innovation, University of New South Wales, Sydney, 2University of South Australia, Adelaide, Australia Objectives: Aim 1: Identify international Performance Indicators (PIs) that are used to report nationally consistent and locally relevant information on healthcare organisations. Aim 2: Review PI sensitivity, specificity and utility; review PIs that have been discarded in other nations, and why; and collate the learning experiences of other nations on the use of PIs to monitor and report on healthcare. Methods: Aim 1: Seven countries with mature systems and which use health care PIs in settings similar to Australia were selected for review – Canada, Denmark, England, the Netherlands, New Zealand, Scotland and the USA. An internet search of PI systems in these countries was performed. The health system performance frameworks for each country were reviewed together with their policy drivers and the PIs being used. Sources included policy documents and consultation with experts. The performance framework domains were compared. The identified PIs were subjected to a detailed assessment including classifying: community/hospital/ population; structure/process/outcome; country of origin and organisation reporting the indicators; evidence for their usage; most relevant healthcare domain; and clinical specialty. Aim 2: A literature review with the guiding question: “what can the academic research and grey literature tell us about the impact of performance measurement regimes on the quality of healthcare?” was undertaken. Semi-‐structured telephone interviews with 13 international experts were conducted. The interviews contained a blend of indicator-‐ specific and generic questions; a thematic analysis of responses was undertaken. Results: The search found 388 PIs fulfilled the criteria. Of these, 45 PIs are reported in more than one country. Effectiveness/appropriateness yielded the most PIs, with 242, followed by access (59), patient experience (47), population health outcomes (34), and efficiency (7). The literature supported the use of PIs with their impact more likely to be on provider rather than consumer behaviour. A logical, acceptable and viable conceptual framework encompassing multiple domains and with balanced representation from structure, process, and outcome PIs, is deemed important. Experts confirmed that having a framework for PIs, reporting publicly, using public reporting to support improvement and leverage change were key factors according with best practice international experience. There were no simple answers to questions such as how many indicators were optimal. Choice of indicators depended to a considerable extent on availability of data and purpose. PI sets should include measures of patient experience. Experts noted that reporting systems and the utility of PIs take time to mature. Using consensus panels for choosing indicators was valuable. Performance frameworks should reflect the government’s and health system’s strategic goals, and may change accordingly over time. Caution is advised in using indicator data to identify high and low performing providers. Conclusion: Best practice national PI reporting systems offer unique learning opportunities. They publish detailed reliability and validity criteria underpinning their indicators, distinguish between two sets of users (public and policy), use standardised and transparent methods for all phases of evidence and PI development, use a balanced approach between process and outcome indicators, and include patient experience PIs. 1417 The Hospital Manager’s Part In Quality Of Care And Patient Safety: A Systematic Literature Review Anam Parand* 1, Sue Dopson2, Anna Renz1, Charles Vincent3 1 Department of Surgery & Cancer, Imperial College London, London, 2Said Business School, 3Department of Experimental Psychology, University of Oxford, Oxford, United Kingdom Objectives: Healthcare managers have are responsible for ensuring good quality of care for their patients. However their work responsibilities are not outlined in the literature, which comprises mostly of opinion articles, editorials, single case experiences and a very limited evidence-‐base.1 Moreover, this limited evidence details challenges rather than an illustration of what part is currently played by managers within this context. This paper reviews the empirical literature to identify the activities, time spent and engagement of hospital managers in quality of care. Methods: A search was carried out on the databases MEDLINE, PSYCHINFO, EMBASE, HMIC. The search strategy covered three facets: management, quality of care, and the hospital setting. Multiple iterations and combinations of all search terms were tested to achieve the best level of specificity and sensitivity. In addition to the key terms, Medical Subject Headings (MeSH®) terms were used, which were ‘exploded’ to ensure inclusion of all MeSH subheadings. Three reviewers (AP, AR and DG) independently screened the titles and abstracts of 15,447 articles and 423 full articles against inclusion criteria. There was a high percentage of inter-‐rater agreement on screening (95% and 89%). Data extraction and quality assessment using a validated assessment scale by Kmet et al2 were performed on 19 included articles. Results: The vast majority of the included articles were based in the US (14 studies) and investigated senior management/Boards (13 studies). Collectively, the evidence indicates that managers at all levels, from Board to frontline managers, are involved in activities that are important to quality and safety. This included strategy-‐setting and reporting, driving improvement culture and promotion of quality and safety. Significant positive associations with quality included establishing strategy to improve care, setting the quality agenda and compensation attached to quality. However there appears to be an inadequate employment of these arrangements and actions. Many managers do not spend sufficient time on quality and safety and have little knowledge on it. For example, in all studies examining time spent on quality and safety by the Board, less than half of the total time was spent on quality and safety, with a majority of Boards spending 25% or less on quality. Findings imply that this may be too low to have a positive influence on quality and safety, as higher quality performance was demonstrated by Boards that spent above 20%/25% on quality. Conclusion: There is a dearth of empirical studies on the hospital manager’s work and its influence, and the studies have a greater focus on the contextual issues surrounding the managers’ part and on time spent at the Board. There is, however, some evidence that Boards’/managers’ time spent and work can influence quality and safety clinical outcomes, processes and performance. We present a model to summarise the conditions and managerial activities that affect quality performance. References: 1. 1 Øvretveit, J. 2009. Leading improvement effectively: Review of research. Available at http://www.health.org.uk/public/cms/75/76/313/560/Leading%20imrpovement%20effectively.pdf?realName=YUa qJk.pdf (accessed 18.08.13). 2. 2Kmet, L.M., R.C. Lee, and L.S. Cook. 2004. Standard Quality Assessment Criteria for Evaluating Primary Research Papers from a Variety of Fields. Edmonton: Alberta Heritage Foundation for Medical Research. 1443 Quality In Nursing – Nurses’ Perspectives On The NNN Taxonomies Hana Konecna* 1, 2, Ondrej Doskocil2, Ludek Sidlo3, Karolina Davidova4 1 Adam Czech Republic, 2Faculty of Health and Social Studies, University Of South Bohemia, Ceske Budejovice, 3Faculty of Science, Charles University in Prague, Prague, 4Philosophical Faculty, Palacky University Olomouc, Olomouc, Czech Republic Objectives: To establish whether the documentation for NNN nursing systems being introduced into healthcare assists nursing staff. To look at some of the potential issues linked to the use of NNN documentation systems within the Czech healthcare system, with particular regard to improving quality. Methods: A combination of research methods: 1. An analysis of the documentation for NNN nursing systems. 2. An analysis of the financial impact of introducing the documentation for NNN nursing systems for health insurance companies and from the organisational perspective and the overall efficiency of the Czech healthcare system. Results: 1. There are various issues concerning the translation of some of the definitions into Czech and whether this may in fact lead to misunderstanding. The taxonomies are complex and offer many definitions for simple concepts, thus increasing the risk of misunderstandings occurring. Some of the coding nurses have to do is time-‐consuming and an additional burden on staff. The overall paperwork burden is increasing and the various systems used do not always fit well together. Nurses are concerned they will be unable to spend sufficient time with patients, which in turn affects the quality of the healthcare the patients receive. 2. There are additional costs, e.g. the extra staffing, training costs which have to be borne by the health insurance companies who have to introduce the taxonomies into their systems. Conclusion: The taxonomies are being introduced in order to improve quality in healthcare by providing a standardised terminology. Translations issues are a serious hindrance to this. Clark and Lang (1992) have argued that “if we cannot denominate it, we cannot control it, practice it, teach it, fund it or make it public”. While, on the other hand, Berg and Bowker (1997) suggest that “pure, quantifiable knowledge…is unattainable”. The concept of tacit knowledge may be more appropriate for quality nursing. References: 1. Berg, Marc / Bowker, Geoffrey C. (1997): The multiple bodies of the medical record: Toward a sociology of an artefact. Sociological Quarterly, 38 (3): 513-‐537 2. Wildawski, A. B. (1988). Searching for Safety. Transaction Publishers. 3. Clark, J. and N. Lang. 1992. "Nursing's Next Advance: An International Classification for Nursing Practice." International Journal of Nursing 39(4): 102-‐12, 128. 1477 Key Functions And Recommendations On Reporting And Learning Systems For Patient Safety Incidents Across Europe Martin E. Bommersholdt* 1, Sonja Barth2, Marcos Manhaes 3 1 National Agency for Danish Patient Safety Database -‐ Learning group, National Agency for Patients' Rights and Complaints, Frederiksberg, Denmark, 2Ärztekammer Berlin, Berlin, Germany, 3National Reporting and Learning System , London, United Kingdom Objectives: This study presents the findings and recommendations of the Reporting and Learning Subgroup (RLSS) in reporting and learning systems for incidents (RLS) in the EU member states [1]. Countries, who wish to establish reporting systems, can use this study as a “catalogue” to gain insight into how EU member states, with established reporting systems, have chosen to organise their reporting system, as inspiration for how the reporting system could be organised. This report take the "WHO Draft Guidelines for Adverse Events Reporting and Learning Systems"[i], the "Council Recommendation 2009/C 151/01"[ii] and the EUNetPaS library [iii] as a basis. It shows how several European countries in different ways have applied knowledge from the WHO and the EU in the establishment and revisions of reporting systems. The following countries have contributed with knowledge about their reporting systems: Austria, Belgium, Croatia, Czech Republic, Denmark, Estonia, Germany, Hungary, Ireland, Italy, Latvia, Luxembourg, Norway, Poland, Slovakia, Slovenia, Spain, Sweden and United Kingdom. In addition there have been representatives from the following organisations and projects: ! European Commission (EC) ! European Health Management Association (EHMA) ! European Patients' Forum (EPF) ! Pharmaceutical Group of the European Union (PGEU) ! European Federation of Nurses (EFN) ! European Hospital and Healthcare Federation (HOPE) ! World Health Organisation (WHO) ! European Union of Private Hospitals (UEHP) Methods: The report is based on the cooperation of EU-‐Member States. This cooperation aims to learn from each other in order to improve health care on national and international level. So the method is the exchange of information, knowledge and national experiences. With this report we give an inside look in how EU-‐Member states establish and run their reporting and learning systems. Results: The result of work is a list of key functions and provide some first recommendations concerning: ! The organisational framework ! Regulatory bodies ! Anonymisation and Confidentiality ! Who can report ! Types of reports ! Voluntary or Mandatory reporting ! Education ! Components of reporting systems ! Procedure of Analysis and feedback ! Implementation of improvement measures ! Technical infrastructure ! Security issues We cannot currently disclose the detailed results when the report, here in February, not has been submitted or approved in EC. Conclusion: Recommendations for countries who wish to establish a reporting and learning system for patient safety incidents. References: 1. WHO, World Alliance for Patient Safety, Draft Guidelines for Incident Reporting and Learning Systems -‐ from information to action, published in 2005. 2. EU Council Recommendation of 9 June 2009, on patient safety, including the prevention and control of healthcare associated infections, (2009/C 151/01) 3. EUNetPas Library of reporting and Learning Systems, 2008 and 2013 located in Patientombuddet, Denmark. 4. Council Of Europe, Committee Of Ministers. Recommendation Rec(2006)7 1529 Team Effectiveness In Clinical Networks: The Importance Of Team Inputs, Participation, And Presence Of Conflict Jill M. Norris* 1, Debbie White1 1 Faculty of Nursing, University of Calgary, Calgary, Canada Objectives: Clinical networks are an emerging interprofessional strategy for improving health service delivery. Yet, little is known about how clinical network members effectively collaborate and work together. The Input-‐Process-‐Output (IPO) team effectiveness model describes dimensions known to influence team success. Inputs provided to teams (e.g. organisational support, team member characteristics) contribute to the interactions or processes between team members and leaders, ultimately creating positive team outputs. This suggests that the effect of inputs on outputs occurs through processes. This study aimed to explore factors that influence team effectiveness, and to test the IPO model in clinical networks. Methods: We performed a cross-‐sectional survey of all members of two clinical networks in Alberta, Canada in 2011 (n=82; 55.4% response rate; 33M and 49F, 45% aged 50-‐59 years). Self-‐reported demographic information and the Aston Team Performance Inventory measures of inputs, processes (objectives, reflexivity, participation, task focus, conflict, creativity, innovation, leadership) and outputs (effectiveness, inter-‐team relationships, innovation, satisfaction, attachment) were collected. Descriptive statistics, subscale means, and scale reliabilities were calculated (Cronbach’s alpha=.75-‐.97). Separate regression analyses were used to test the IPO model for each output in turn. First, we estimated the relationships between inputs and each process. Next, hierarchical regressions were conducted to estimate the relationship between inputs with outputs in the first step. In the second step, process variables were added to establish the relationship between the proposed mediating variables with outputs. Results: The full IPO model explained 45% to 77% of the variance in outputs, with each output predicted by different variables. Team processes fully mediated the effect of inputs on outputs for satisfaction, attachment, and innovation, and partially mediated the effect in predicting team effectiveness. Participation (b=.71, p<.001) and task focus (b=.27, p=.051) predicted team member satisfaction, while task focus (b=.39, p=.074) predicted attachment, the extent to which members felt committed to remain part of the team. Inputs (b=.55, p=.005) were the sole significant predictor of inter-‐ team relationships. Both reflexivity (b=.27, p=.033) and creativity (b=.29, p=.067) predicted development of innovations. For perceived team effectiveness, inputs (b=.71, p=.004), participation in decision-‐making (b=.57, p=.036), and the presence of team conflict (b=.37, p=.034) were important predictors. Given the negative correlation between team conflict and effectiveness (r=-‐.28, p=.012), we conducted exploratory analysis by removing each input and process variable in turn from the full regression model. Conflict and participation only predicted effectiveness when together in the same model. Moreover, task-‐related conflict—not interpersonal conflict—predicted effectiveness. Leadership processes and team objectives did not independently predict any output. Conclusion: Inputs enable collaboration between team members, and results suggest that health systems can optimize team effectiveness and inter-‐team relationships by ensuring organizational support/resources and a well-‐designed task for the right team members. Clinical networks that foster full engagement and debate in decision-‐making may also be more effective. Current research underway with nine strategic clinical networks will further explore these preliminary findings through mixed-‐methods and robust statistical modelling with objective measures of performance (i.e., clinical/system outcomes). 1544 Korea's Specialty Hospital System Da Won Jung* 1, Sang Ji Kim1, Nam Surk Lee1, Soo In Kim1 1 Health Insurance Review & Assessment Service (HIRA), Seoul, Korea, Republic Of Objectives: In 2011, Health Insurance Review & Assessment Service (HIRA) started to designate and assess Specialty Hospital every three years by the order of the Minister of Health and Welfare. This study was performed in order to explain the designation and assessment process of the Specialty Hospital in Korea. Methods: The Specialty Hospital's designation and assessment process is as follows: 1. The Ministry of Health and Welfare announces the plan of designation of the Specialty Hospital. 2. The institution (hospital or higher level) submits an application to the Ministry of Health and Welfare. 3. The hospital submits assessment data to HIRA. (assessment data: facility, workforce, treatment result) 4. HIRA evaluates the institution according to the criteria. (assessment method: data analysis, data check, field survey, designation criteria (7)*) 5. The assessment results are reported to the Ministry of Health and Welfare. 6. The Ministry of Health and Welfare issues a Specialty Hospital certificate to the selected institution. ** Designation field (20): Spine, Cerebrovascular, Colonal, Finger inosculation, Heart, Alcohol, Breast, Joint, Burn, Obstetrics and Gynaecology, Paediatrics, Neurology, Neurosurgery, Ophthalmology, Surgery, ENT, Rehabilitation, Orthopedics, Oriental medicine (Spine, Stoke) ** Designation criteria (7): clinical quality*, ratio of patients configuration, treatment quantity, required treatment subject, workforce, sickbed, medical service level ** (Clinical quality (ex)) Clinical quality Indicators of spinal diseases 1. Structure Indicators: Number of patients per specialist per day (Neurosurgeon, Orthopaedist), Number of patients per physical therapist per day, Nursing grade (nurse-‐patient ratio), Number of departments (Anaesthesiology, Rehabilitation, Radiology) 2. Process Indicators: Number of past medical history records, Presence of disease onset records, Number of records of patient condition, Rate of treatment planning at admission, Completion rate of medication and physical therapy period 3. Outcome Indicators: Length of hospital stay(days) per case (Lengthiness Index, LI), Rate of complication after operation, Rate of re-‐ operation within 30 days of operation, Rate of re-‐admission within 30 days of discharge, Number of MRI scan, Number of Sonography, Extra tests and Materials for medical treatment Results: The total of 132 hospitals applied to HIRA for Specialty Hospital Designation in 2011. Ninety nine hospitals were designated as Specialty Hospital (general hospitals 11.1%, hospitals 79.8%, long-‐term care hospitals 2.0%, and oriental hospitals 7.1%). HIRA conducts monitoring on Specialty Hospitals every six months. As of 2013, there were 2.1% of general hospital, 83.3% of hospital, 1.1% of long-‐term care hospital, 7.8% of oriental hospital, and 9 institutions failed to meet the criteria during this monitoring period. Conclusion: The Specialty Hospital System of Korea has been successfully implemented. HIRA is going to re-‐select Specialty Hospitals in 2014. We expect to see enhanced quality in Special Hospital. 1632 The Present Situation And Future Trends Of Hospital Accreditation In Mainland China Jishan Wang* 1 1 National Institute of Hospitals Administration, Beijing, China Objectives: The purpose of this paper is to review the present situation and future trends of hospital accreditation in Mainland China. Methods: Apart from the current regulations, this paper collected related information from some available channels: websites, personal communications, etc. Results: The whole hospital evaluation system framework of Mainland China consists of five parts: First, the national relevant laws, regulations and standard. In 19941, 20092, and 20113, the government issued three important policies about hospital accreditation respectively. Second international experiences and standards. The present hospital accreditation referred to some international hospital accreditation experiences, particularly the United States, and involved the concepts of evidence-‐based medicine and patient-‐centered service. Third independent third-‐party hospital accreditation agencies. Some provinces and cities has established local accreditation agency, Shanghai Shen Kang Hospital Development Center4 is the representative case. Fourth nationwide professional judges team. According to a series of training courses and practices, 200 judges got the qualifications by the end of 2013. Fifth scientific and objective information evaluation. The present accreditation paid more attention on the data about hospital quality, and got the objective evaluation results through the scientific data analysis. Conclusion: The practices of hospital evaluation showed that the hospital review evaluation play an important role of promoting the national hospital quality effectively. References: 1. Former Ministry of Health. Detail rules of Medical Institution Regulations. 1994,02 2. Former Ministry of Health. Hospital Evaluation Criteria (Draft). 2009,06 3. General Office of Former Ministry of Health. General Office of Former Ministry of Health. < Notice of General Office of Ministry of Health Concerning the release of > [Z]. 2011,11. 4. Shanghai Shen Kang Hospital Development Center. http://www.shdc.org.cn 1637 Co-‐operative Leadership In The Implementation Of Quality Systems: Structure, Process And Outcome Relationships Vanessa Burkoski* 1, Jennifer Yoon1 1 London Health Sciences Centre, London, Ontario, Canada Objectives: The objective of this study was to analyse the relationships between structure, process and outcome, and discuss implications of these relationships on the implementation of quality systems. Health care organisations design and establish quality improvement efforts by implementing quality systems. Wruck and Jensen (1994) defined quality improvement as a scientific, non-‐hierarchical application of technologies that increase an organisation’s efficiency and quality. The critical factor for achieving quality in organisations is based on the cost of transferring information between individuals at all levels for everyday decision-‐making (Jensen & Meckling, 2009). The exchange of agent-‐specific knowledge (insight gained at the point-‐of-‐care) regarding strategies to improve quality can be enhanced by the integration of a shared governance model. Continuous Quality Improvement (CQI) councils were implemented across the second largest academic health sciences centre in Canada with the aim of leveraging agent-‐specific knowledge at the point-‐of-‐care and providing the structure and process to build human resources capacity to identify, formulate, execute, and evaluate CQI initiatives. The application of Donabedian’s framework enabled component parts of the implementation to be systematically analysed in the context of quality systems. Methods: A convenience sample of management and front-‐line staff across 63 CQI councils responded to a validated questionnaire with measures reflecting each component (structure, process, and outcome) of Donabedian’s framework (Kunkel, Rosenqvist, and Westerling, 2007). Results: Results of the analysis revealed significant relationships between structure, process, and outcome as they relate to quality systems. Conclusion: Conclusions drawn from this study suggest that co-‐operative leadership in the implementation of quality systems may enhance the formation of a culture of continuous improvement. Findings from this study may support health care organisations ability to select appropriate strategies for implementing effective quality systems. References: 1. Jensen, M.C. and W.H. Meckling. 2009. “Specific Knowledge and Divisional Performance Measurement.” Journal of Applied Corporate Finance 21(2):49-‐57. 2. Wruck, K.H. and M.C. Jenson. 1994. “Science, Specific Knowledge and Total Quality Management.” Journal of Accounting and Economics 18:248-‐87. 3. Kunkel, S., U. Rosenqvist and R. Westerling. 2007. “The Structure of Quality Systems is Important to the Process and Outcome, An Empirical Study of 386 hospital departments in Sweden. BMC Health Services Research 7(104) doi: 10.1186/1472-‐6963-‐7-‐104. 1740 Management By Walk Rounds In A University Hospital: Deployment And Evaluation Of Visiting Managers’ Satisfaction Aimad Ourahmoune* 1, Gaelle Dessard-‐Choupay1, Anne-‐Claire Rae2, Pierre Chopard1 1 Medical and Quality Directorate, 2Nursing Directorate, University Hospital of Geneva, Geneva, Switzerland Objectives: The walk rounds management program of the University Hospital of Geneva (HUG) entitled QuaP (Quality oriented towards the Patient) including all 113 care units in our institution started in August 2012 and is an ongoing process in our institution. Its objectives are to develop a common culture of quality, identify units’ strengths and weaknesses and highlight areas for improvement. The purpose is not to evaluate employees or stigmatise units. Methods: Units are visited by a tandem combining physician or nurse with an administrative executive (top or middle manager). A 1 and 1/2 hour session regarding awareness on how to lead the visit is given to all. Participants are not allowed to visit their own department. A visitor’s guide serves as a helping support. Each care unit is to be visited at least three times a year. The visit lasts 1 hour and 30 minutes and includes a total of 65 questions divided into 5 domains: general observation, interview with a patient or relative, interview with a doctor or nurse, review of medical and nursing records. Potential good ideas or critical points are highlighted at the end of the visit. A computer application was developed and all observations are entered on a tablet. The results are presented as a colour mosaic synthesising the last 6 visits with chronological tracking scores and are accessible to unit leaders and services with an individual code. A satisfaction survey was done in September 2013 among 169 visitors who conducted at least one visit at the time of the survey. Results: After 18 months of deployment (August 2012-‐ January 2014), 335 visits have been carried out involving 181 visitors. 77 % of the units have been visited 3 times or more, 20 % twice and 3 % once. The response rate of visitor’s satisfaction study was 66% (112/169): heads of medical departments 40% (8/20), and physician executives 67 % (43/64), nursing executives 82 % (18/22); administrative executives 56% (35/63), and 8/112 unknown. Median number of visits per visitor was 3 (1 to 10). Responders affirmed that this visit’s concept enables: to improve the quality of care in HUG (75%), to identify potential areas of improvement for the units visited (74%), to better understand how other areas work (85 %). 68% of visitors believe that this initiative strengthens the multi-‐disciplinary and inter-‐departmental dialogue. 75 % of the heads of medical departments, nursing and administrative executives believe that conducting these visits is their role, whereas only 40% of senior physicians agree. The reception by the visited teams is good (99%), collaborators are available (94%) and able to interact with the visitors (99%). The questions are considered to be relevant (84%) but there are too many questions (70%). Visitors wish to have less than 4 visits per year (59%) and 72% of visitors are generally satisfied with their visits (57% physicians, nurses and administrative 88%). Conclusion: The project is now deployed across all care units. It is generally acceptable to visitors but less by senior physicians who believe that these visits do not correspond to their mission. This project has led to several actions for improvement initiated by the care units themselves. The next steps will be to assess the satisfaction of care units’ staff, to document actions for improvement following the visits and to revise the visitor’s guide according to the results of the satisfaction survey. 1885 Performance Monitoring Of Group Practices In Hungary Norbert Kiss* 1, Tamas Gergely2, Eszter Sinko3, Csaba Dozsa4 1 Institute of Management, Corvinus University of Budapest, 2Applied Logic Laboratory, 3Health Services Management Training Centre, Semmelweis University, Budapest, 4Miskolc University, Miskolc, Hungary Objectives: Our objective was to adapt the PC Monitor framework, set up by Kringos et al. (2010), to describe the performance of group practices, and use this modified framework for monitoring the performance of a pilot project in Hungary. It is also reviewed whether and how the adapted PC Monitor system could serve as a general tool to monitor the performance of local health services and provide feedback for group practices. Methods: The PC Monitor was created in order to serve as a model for the holistic analysis of primary care services and to provide a framework for the comparison of European primary care systems. It resulted in a number of indicators, describing the structure of GPs (governance, economic conditions, workforce), their operational processes (access, comprehensiveness, continuity, coordination), and the outcomes (quality, efficiency, equity). Effective coordination of primary health care and community services is key for the improvement of the health status of the population. In Hungary primary care is mainly provided by single-‐handed general practitioners, community midwives, and dentists without any formal, and usually without any informal, coordination among them, thus better integration of these services is a key policy objective. A Hungarian pilot project, funded from the Swiss Contribution, was initiated in order to test how community-‐based, public health focused operation of local service providers with e-‐health support could improve the performance of local health services. During the pilot project four group practices have been established, each consisting of six GPs and their assistants as well as other local level key staff: local public health coordinator, public health expert, community nurse, diabetologist, psychologist, physiotherapist, midwives, a medical resident in family medicine and community coordinators. The four pilot group practices have been set up in areas where there is a high ratio of Roma population. The aims of the pilot project are to improve the coordination among local health care providers as well as to improve access to care and decrease health inequalities, especially for the Roma population. E-‐health and operating “virtual practices” are seen as an important enhancer during the process, and the project includes an IT development component as well: workflows of the group practice will be assisted by a common IT platform. A series of expert workshops led to the first version of the adapted framework. Initial quantitative and qualitative data about the performance of the pilot group practices are being collected from the central health insurance fund database, the local medical IT systems, participant surveys and interviews. Results: The first results of the monitoring of the ongoing pilot project are presented. The performance monitoring model is refined by using the data. Conclusion: It was found that the dimensions of the original PC Monitor model are adequate for monitoring the performance of group practices; however, several indicators were modified, removed or added. The reports produced by using the framework could be valuable tools for professionals to monitor the performance of group practices and integrated local public health services. References: Kringos et al. (2010): The European primary care monitor: structure, process and outcome indicators. BMC Family Practice, 11:81. http://www.biomedcentral.com/1471-‐2296/11/81 1922 Do French General Practitioners Use Quality Indicators Results To Refer Their Patients To Hospitals? Marie Ferrua* 1, Benoit Lalloue1, Claude Sicotte2, Etienne Minvielle1 1 PRIQS, EHESP/MOS, Villejuif, France, 2PRIQS, EHESP/MOS/Université de Montréal, Montréal, Canada Objectives: Since 2006, French national authorities oblige hospitals to collect quality indicators (QI) and provide access of results to the public. In France, GPs play a key role in deciding patients’ hospitalisation and among patients’ criteria when choosing a hospital, the advice of GPs is most important. This study was aimed at investigating GPs’ perception and knowledge of QIs and their use for hospital referral. Methods: A survey of 1230 GPs randomly selected from 54579 registered GPs in the national Shared Directory of Healthcare Professionals (RPPS) was conducted. Selected GPs were provided a letter explaining the objectives of the survey. The survey consisting of 40 questions was developed by the research group and validated by representatives of the French GPs Medical Society. Their survey answers were recorded through phone calls. GPs were asked questions about: ! Their opinion concerning QIs’ relevance, comprehensibility and utility for hospital choice; ! Their knowledge of the national authority website responsible for public QIs diffusion; ! When giving advices for hospital choice, if they use: QIs, rankings published by magazines, data found on non-‐ governmental websites, or other criteria; ! Their opinion concerning topics proposed by the French GPs Medical Society. The answers were rated on a five point Likert scale (1=strongly disagree to 5= strongly agree) or (1=Never to 5=Always). Results: Out of the 900 GPs (73.2%) eligible to be interviewed by phone, 503 (56%) accepted to participate in the survey. Their characteristics were similar to the GPs national distribution concerning age, sex and region. Globally GPs had a positive opinion of QIs. The majority of GPs agreed or strongly agreed that QIs were relevant to measure quality of care, that QIs could help the choice of a hospital, and that they were easy to understand. QI Relevance QI help for hospital choice QI easily understood Agree or strongly agree (%) 37 43 37 Disagree or strongly disagree (%) 28 31 24 Indifferent (%) 20 15 15 Don’t know (%) 15 11 25 However, 94% of GPs were not aware of the official website where all hospital QIs results are available. When giving advices for hospital referral, GPs used (always or often) different criteria than that of the national authorities’ data: previous experience of hospital referral (92%), inter-‐professional relations (87%), distance to hospital (86%) and patients’ preferences (70%). On the contrary, 88% of GPs say they never used data from national authorities, but they did not use neither rankings published in magazines nor other websites. Among topics proposed by the French GPs Medical Society, GPs agreed or strongly agreed on the interest of data on quality of coordination between hospital and primary care (82%), data on patients’ experience or satisfaction (75%) and pressure ulcer rates (73%). Conclusion: GPs seem to have some interest in hospital quality of care measurements by QIs, however they lack knowledge of existing hospital mandatory QIs and they seldom use them when counselling patients. A new website of the national authority for health has been designed to help advance the quality of hospitals, which could potentially enhance the knowledge of GPs. 1937 Measuring Social Capital In European Hospitals: Psychometric Properties Of A Questionnaire For Chief Executive Officers Antje Hammer1, Holger Pfaff* 1, Oliver Groene2, Rosa Sunol3 1 Institute for Medical Sociology, Health Services Research and Rehabilitation Science (IMVR), University of Cologne, Cologne, Germany, 2Health Services Research Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom, 3Avedis Donabedian Research Institute, Universitat Autonoma de Barcelona, Barcelona, Spain Objectives: Decisions regarding investments for quality improvement and the implementation of quality improvement systems are largely based on the commitment of hospital management. Hospital managers are essential decision makers. They set directions for the organisation and guide efforts for successful quality improvement. According to the concept of social capital, common shared values and mutual trust among the hospital management board members are essential requirements for successful cooperation and coordination within groups. Therefore the purpose of this study is to validate a survey to assess Social Capital within the hospital management board (SCB) in European hospitals. Methods: Data were gathered as part of the EU funded project “Deepening our understanding of quality improvement in Europe (DUQuE)”. We used a mixed-‐method approach for data collection and measurement from 210 hospitals in 7 European countries (Czech Republic, Germany, France, Poland, Portugal, Spain, and Turkey). The SCB-‐scale is a six-‐item survey completed by the chief executive officers (CEO) asking about their perceptions of social capital within the hospital management board. Answers were rated on a 4 point Likert scale ranging from ‘strongly disagree’ (1) to ‘strongly agree’ (4). The sum of the six items was divided by six, so the total scores ranged from one to four points. Following descriptive statistics, we explored the factor structure of social capital in an exploratory factor analysis, tested internal consistency (Cronbach’s Alpha) and analysed construct validity using Pearson’s correlation coefficients between the scale items. Results: Overall, 188 hospitals participated in the DUQuE-‐study. Of these, we received 177 completed questionnaires from hospital CEOs. Moreover, due to missing values, we counted 172 observations for social capital. The average SCB-‐mean of 3.02 (SD=0.61) showed that hospital CEOs perceive relatively high social capital within the hospital management boards. The exploratory factor analysis resulted in a 1 factor-‐model with Cronbach’s alpha =.91. Pearson’s correlation coefficients ranged from 0.48 and 0.68 between the single scale items. Conclusion: From the management perspective, it is necessary to assess how the top-‐management of a hospital, especially the CEO, assesses social capital within the hospital management board. The results showed an acceptable level of reliability for SCB. Tests of the construct validity also proved that the SCB-‐scale is eligible for measuring social capital in European hospital management boards from the CEO’s point of view. 2166 Malaysian Patient Safety Goals -‐ Singular Benchmarking In Malaysian Healthcare * 1 Nor'Aishah Abu Bakar 1 Patient Safety Unit, Healthcare Quality Section, Ministry Of Health Malaysia, Putrajaya, Malaysia Objectives: Malaysia has made a significant evolution in patient safety last year as Malaysian Patient Safety Goals (MPSG) was launched during st the 1 National Patient Safety Campaign 2013. The objective of this paper is to share the Ministry of Health Malaysia experience in developing and implementing the MPSG. This is the first time Malaysia has established a singular benchmarking on patient safety which is applicable to public and private health care. Methods: The main objectives of the Malaysian Patient Safety Goals are: 1. To outline important areas in patient safety with specific goals and targets 2. To evaluate the status of patient safety in Malaysia. For hospitals, there are 13 goals and 19 performance indicators whereas for clinics, there are 4 goals and 6 performance indicators. The goals were developed based on WHO patient safety priority areas and consensus of a technical committee. Performance indicators were also added to enable more systematic monitoring of the related goals. Targets were based on philosophy of the MPSG, national and international standards, current Malaysian performance and input from WHO. Multiple strategies were used to ensure successful implementation of MPSG. These are: 1) 2) 3) 4) 5) 6) 7) 8) 9) Endorsement of the Patient Safety Council Formal directive through the Director General of Health circular No. 2/2013 to establish Patient Safety Committee in health care facilities and implement MPSG Production of MPSG – Guidelines on Implementation and Surveillance Establishment of “e-‐goals patient safety” web-‐based online notification and monitoring system to facilitate notification of achievement from health care facilities to the Patient Safety Council Secretariat. Each health care facility are also responsible to monitor its performance and take necessary steps to improve patient safety. Launching of MPSG at national level Specific training on MPSG and presentation at seminars and conferences th Incorporating MPSG into 4 Edition Malaysian Accreditation Standard Media campaign on patient safety and areas related to MPSG Using Patient Safety Council Website and Patient Safety Malaysia Facebook to deliver important information on MPSG. Results: Malaysia has seen a “tsunami” on patient safety awareness following the launching of MPSG throughout the country in both public and private sector. Not only in hospitals but also in clinics. In terms of performance notification, preliminary result showed that notification was more among the government health care facilities in comparison to private. Amongst the challenges faced are: 1) 2) 3) 4) 5) Developing the goals, suitable performance indicators and targets Dissemination of information on the goals, technical specification and methods of notifications Development of the online notification system Data collection, analysis and feedback mechanism to relevant stakeholders Evaluating the impact of MPSG in improving patient safety. Conclusion: Malaysia has been very bold in implementing MPSG throughout the country. First six months of implementation has shown positive impact in increasing awareness on patient safety. Nevertheless more aggressive promotional activities on MPSG need to be conducted throughout the country to ensure the message is delivered to all facilities, particularly in private sector. The next phase of action is to use MPSG indicators to evaluate the status of patient safety in the country and taking appropriate remedial measures. 2203 Establishment Of Guidelines For Safe Invasive Procedures Hui-‐Chin Wang1, Chien-‐Te Lee* 1, Jiin-‐Haur Chuang 1 1 Council for Quality Health Care, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung, Taiwan Objectives: To improve safety and reduce risk of surgery, the World Health Organization (WHO) has proposed guidelines for safe surgery in 2008. Hospital National Patient Safety Goals also suggest to inspect all surgical and nonsurgical invasive procedures. However, there was no strict surveillance on safe nonsurgical invasive procedures, which included time-‐out and hand-‐over routinely performed in surgical procedures. The study aimed to achieve the goal of safety in non-‐surgical invasive procedure. Methods: The guidelines of inform consent and checklist had been set-‐up since 2002 in our hospital, but available for those of non-‐ surgical invasive procedure only until 2012. A time-‐out step was included as the second check-‐point. For time-‐out, patient identification, correct location of ongoing procedure and supplementary information were included. Furthermore, post-‐procedural check-‐up was also of crucial importance. This included physical examination, assessment of psychological status, correct specimen submission and lastly inspection of equipment and place for invasive procedures. Results: In 2012, eight divisions have set-‐up their guidelines for invasive procedures. For another 113 non-‐invasive procedures in 16 divisions, various checklists were also present. On average, there were 5,700 procedures under time-‐out inspection in one month. All these procedures have been investigated and analysed. The implementation of time-‐out policy was well-‐ adapted in examination units, but not in emergency room and some wards. Conclusion: The policy of time-‐out prior to any invasive procedures provides validation and comprehensive safety. However, it takes time to complete all check-‐ups and finish documents. Revisions of the indications and contents of time-‐out are mandatory in the near future. References: 1. World Alliance for Patient Safety. WHO guidelines for safe surgery. Geneva: World Health Organization, 2008. 2. Checklists for Invasive Procedures N Engl J Med 2013; 368:293-‐294January 17, 2013 3. National Patient Safety Goals Effective January 1, 20142013 The Joint Commission 2213 Job Dissatisfaction And Turnover Intention Of Contract Nurses In Hospitals In Guangdong Province In China Jing Zheng* 1, Liming You1, Ke Liu1 1 School of Nursing, Sun Yat-‐sen University, Guangzhou, China Objectives: In the last three decades, more and more Chinese hospitals have employed contract nurses who sign contracts with hospitals every 1 to 5 years while receive relatively less salary and benefits than the “Bianzhi” nurses. This study aims to compare the differences of job dissatisfaction and turnover intention between contract nurses and “Bianzhi” nurses. Methods: This was a cross-‐sectional study. One thousand and twenty-‐seven bedside nurses including 590 contract nurses and 437 “Bianzhi” nurses were surveyed in 2008-‐2009 from 89 medical, surgical and intensive care units in 21 hospitals across the Guangdong province in China. Nurses’ Job dissatisfaction were measured by one item on nursing career satisfaction combined with 8 items specified on work schedule, opportunities for advancement, independence at work, professional status, salary, healthcare benefits, retire benefits and tuition benefits. Turnover intention was measured by a single-‐item asking whether they plan to stay with the current hospital in the next year. Chi-‐square tests were used to compare the proportion of turnover intention between these two kinds of nurses. Multivariate logistic regression models were conducted to estimate the relationship between job dissatisfaction and turnover intention, controlling nurses’ demographic factors (gender, marital status, years as nurse, initial nursing education and highest nursing degree) as well as unit type and hospital characteristics (rank, technology, location, proportion of contract nurse and nurse to bed ratio). Results: About 57% of clinical first-‐line nurses in hospitals in Guangdong were contract nurses. Among them, 85.7% were younger than 30 years old and 66.2% of them worked for less than 5 years as a nurse. They were younger and working fewer years than “Bianzhi” nurses. Both contract nurses and “Bianzhi” nurses were dissatisfied with most aspects of their job. Almost 80% of contract nurses were dissatisfied with salary, in which 39.7% of them were “very dissatisfied”, whereas the percentage of “very dissatisfied” with salary in “Bianzhi” nurses was 30.3%. Contract nurses had a significantly higher rate of turnover intention (10.7%) than the “Bianzhi” nurses (3.7%, χ2= 16.68, p<0.01). When compared with contract nurses, more “Bianzhi” nurses tended to be dissatisfied with their job in terms of career development, professional status and opportunities for advancement. After controlling for hospital and unit characteristics and individual nurse factors, nurse’s job dissatisfaction was significantly associated with turnover intention. The contract nurses who were dissatisfied with healthcare benefits (odds ratio [OR] 2.006; 95% confidence interval [CI] 1.278-‐3.148; p<0.01), salary (OR 1.906; 95% CI 1.039-‐3.496; p<0.05) and nursing career (OR 1.750; 95% CI 1.148-‐2.669; p<0.01) were significantly more likely to have turnover intention, and the “Bianzhi” nurses who were dissatisfied with healthcare benefits (OR 2.298; 95% CI 1.060-‐4.983; p<0.05) and nursing career (OR 2.968; 95% CI 1.273-‐ 6.922; p<0.05) were significantly more likely to have turnover intention. Conclusion: Contract nurses had become the main workforce in clinical nursing care in Guangdong province in China. However, the contract nurses were dissatisfied with most aspects of their job especially with salary. The discrepancies in payment and benefits between contract nurses and “Bianzhi” nurses resulted in higher rate of turnover intention in contract nurses. The policy of equal pay for equal work should be emphasised by Chinese government and implemented in hospitals for the sake of alleviating the losses of contract nurses. 2225 Patient Satisfaction Survey In Hong Kong – A Tool To Engage Staff And Patients For Quality And Patient-‐Centred Care 1 1 * 1 1 Roy Tsui , Richard Au Yeung , Victor Leung , Pauline Wong 1 Hospital Authority, Hong Kong, Hong Kong, Hong Kong Objectives: Against the background of rising community expectation for better care and higher accountability, the Hospital Authority (HA) being the major public healthcare provider in Hong Kong, has followed the international trend of employing satisfaction survey to measure and monitor patients’ experience. The first Benchmark Patient Satisfaction Survey (PSS) was conducted in 2010 by an independent academic institution for more than 5,000 discharged patients in 25 public hospitals. This was the first survey of such scale in Hong Kong and in any Chinese community in Asia using a validated instrument. High ratings were recorded in the areas of (a) confidence and trust to doctors and nurses (>87%); (b) overall impression of service (80%). An overall Corporate PSS Service Plan has been constructed for the coming 5 years (2014/15 – 2018/19). A structured mechanism is also in place to link up follow-‐up action plans with the governance framework. Methods: In the Hong Kong public healthcare setting, we have attempted to measure the effect of the PSS particularly towards the core value of engagement and patient-‐centred care through two studies: ! ! Hospital-‐based (HB) PSS; and Patient Engagement Study (PES) in 2013/14. In a number of countries, healthcare workers’ attitudes towards patient experience surveys and patient feedback reports in general have been found to be broadly positive. Some healthcare workers might remain sceptical about the value of PSS. With a view to looking into whether there would be sustained momentum for PSS over time, and whether the PSS has positive impact/attitude change on both patients and staff, the following 2 studies were conducted in 2013 using validated instruments by an independent academic institution in collaboration with the HA: 1. 2. HB PSS in 7 major acute hospitals for 3,600 discharged patients Mirroring the first Benchmark Survey, the HB PSS capturing views of 3,600 patients in 2013 would provide useful information that could be used for comparison with that of the 2010 Benchmark Survey. PES on 410 doctors, 2,300 nurses and 1,000 discharged patients The PES assessed both staff and patients’ views/attitude towards patient-‐centred care. The overall aim is to gather both staff and patients’ feedback on patient engagement experience. In particular, their views (experiences) in routine practice as well as ideas/suggestions on how best to incorporate patient engagement in the care process were solicited. Results: Based on the interim results from the above 2 studies, it is encouraging to note the following from the validation survey findings: a) results of 2013 HB PSS are comparable to that of the 2010 Benchmark PSS; b) the high return rate for PES has exceeded our expectation (55% for doctors, 62% for nurses and 63% for patients). The research agent is now at the final stage of data analysis. It is envisaged that the full report will be available by end of first quarter 2014 for sharing at the ISQua Conference. Conclusion: Since the 2010 Benchmark Survey, PSS has become an integral part of the governance framework to engage patients to improve quality for patient-‐centred care. Significant progress has been made for systematic planning and development of PSS in HA. Initial impression from the high ratings recorded from the 2013 validation survey for HB Survey, as well as high return rate on the PES, has suggested sustained momentum with a high degree of engagement for both staff and patients towards PSS and patient-‐centred care. 2360 No Fault Competition For Blood Sampling (Venipuncture) Related Adverse Events: Attitude Of The Japanese Medical Institutions * 1 2 3 Shoichi Maeda , Etsuko Kamishiraki , Rika Kanagawa 1 2 Graduate School of Health Management, Keio University, Fujisawa, Department of Social Welfare, Yamaguchi Prefectural 3 University, Faculty of Social Welfare, Yamaguchi, Department of Nursing, Shonan Chuo Hospital, Fujisawa, Japan Objectives: Background: Adverse events can occur in relation to blood sampling (venipuncture).The Japan Red Cross has reported about 1% (5-‐6000/year) of such events among their blood donors. In Japan a system has been established for no fault compensation for the blood donors in 2006 and likewise for adverse events (severe cerebral palsy) in relation to childbirth in 2009. In view of these, no fault compensation has been debated for venipuncture-‐related adverse events more recently. As for blood donation and childbirth, determining the presence of clinical negligence in venipuncture-‐related adverse events is difficult, resulting in many medical conflicts and civil litigations. Objective: To investigate the medical institutions’ attitude towards no fault compensation for the adverse events associated with venipuncture. Methods: Of all the medical institutions founded by a member of Japan Medical Association, 938 hospitals (20.0% of total 4688) and 1468 (2.0% of total 73402) medical clinics have been randomly selected for the study. An anonymised questionnaire was posted to the hospitals and clinics to explore their views on no fault compensation for venipuncture-‐related adverse events. The study period was between 8th and 28th December 2011. SPSS Statistics 20 was used for the statistical analysis of the data. Chi-‐square test or Direct Fisher test was used to assess the associations between the sets of the relevant results. Unanswered questions were treated as missing data and excluded from the analysis. Results: 201 (21.4%) hospitals and 418 (28.5%) clinics responded. Many of them desired for a no fault compensation system to be placed and their desire had no correlation with their prior experience of medical conflict or litigations. (Table1(1)) In case such a system was placed who they thought should take the responsibility for paying out the compensation was as shown on Table 1(2). Table 1: (1) Views on needs for no fault compensation for venipuncture-‐related adverse events in relation to the prior experience of conflicts and litigations, (2) Who should pay the no fault compensation. (1) Views on needs for no fault compensation System needed Hospital (n=201) n (%) Prior experience No Yes 31 (68.9) 22 (75.9) System not needed 14 (31.1) (2) Who should pay the no fault compensation* Medical institutions Patients Government Other 7 (24.1) Hospital (n=142) n (%) 55 (38.7) 17 (12.0) 102 (71.8) 8 (5.6) P 0.516 Clinic (n=418) n (%) Prior experience No Yes P 65 7 (77.8) 1.000 (76.5) 20 2 (22.2) (23.5) Clinic (n=316) n (%) 113 (35.8) 44 (13.9) 232 (73.4) 26 (8.2) Total (n=641) n (%) Prior experience No Yes P 96 29 0.759 (73.8) (76.3) 34 9 (23.7) (26.2) Total (n=460) n (%) 169 (36.7) 61 (13.3) 335 (72.8) 34 (7.4) *Multiple responses Conclusion: Many medical institutions desire for a system for no fault compensation for venipuncture-‐related adverse events. Such a system would support the affected patients financially even when there was no medical negligence. Many of them also believe that they should be responsible for paying the compensation despite the general perception that the medical institutions are not required to pay compensation when there was no fault on their side. The reason behind such a belief would be worth exploring before establishing the system. 2388 A Pilot Study Of Workplace Violence Experienced By Nursing Personnel Chia-‐Ling Hsu* 1, Chun-‐Lin Chen2, Yu-‐Chun Lin1 1 Department of Psychiatric Nursing, 2Department of Psychiatry, Far-‐Eastern Memorial Hospital, Taipei, Taiwan Objectives: Nursing personnel must not only cope with physically and mentally taxing responsibilities in today's medical environment but are also frequently exposed to different workplace violence scenarios. The deterioration in the workplace environment has in turn accelerated the desire by nursing personnel to leave the workplace. The purpose of this study is therefore to understand the types, frequency and experience of violence encountered by nursing personnel in medical institutions. Methods: The research was carried out as a cross-‐sectional survey with a self-‐made questionnaire as the research tool for collecting samples. A certain medical center in New Taipei City was used for case collection and the subjects consisted of nursing personnel working in the medical-‐surgical wards of the medical center. A structured survey was conducted between October 28 and November 4, 2013, with a total of 39 cases collected. The survey statistically analysed using the SPSS 17.0 Windows software package. The means, frequency distribution and percentages were then used for descriptive statistical analysis. Results: The results were as follow: 100% were female; average age was 29.8 years; 69.2% were unmarried; 69.2% held an university degree; 89.7% were nurse practitioners; average seniority was 6.9 years; 94.9% were full-‐time employees; 84.6% were on a 3-‐shift roster; 48.7% had experienced more than one incidence of physical violence; 51.3% had witnessed other nursing personnel being subjected to physical violence; the main perpetrators of physical violence consisted of patients (50%), patient's friends and relatives (30%) and doctors (5%); physical attacks consisted of kicking (69.2%) and manhandling (69.2%). 48.8% of nursing personnel who had experienced more than one incident of psychological violence; 51.3% of nursing personnel had witnessed other people being subjected to subjected psychological violence; the perpetrators consisted of patients (27.1%), patient's friends and relatives (23.7%), doctors (19.6%) and nursing colleagues (16.9%); psychological violence took the forms of offensive or humiliating language (82.1%), and language attacking values (82.1%). Conclusion: Workplace violence against nursing personnel is now a common occurrence and the damage done by constant abuse is making clinical nursing personnel shy away from entering the workplace. This study hopes that the results will help clinical nursing personnel review their situation so that they will not be more aware of their own personal safety but also refuse to tolerance any incidences of workplace violence. Early intervention is necessary to avoid further reoccurrence. References: 1. Campbell,J.C.,Messing,J.T.,Kub,J.,Agnew,J.,Fitzgerald,S.,Fowler,B.,et al.(2011).Workplace violence Prevalence and Risk Factors in the Safe at Work Study. American College of Occupational and Environmental Medicine,53 (1).82-‐89. 2. Farrell, G. A., Bobrowski, C., ＆Bobrowski, P. (2006). Scoping workplace aggression in nursing: findings from an Australian study. Journal of Advanced Nursing, 55 (6),778-‐787. 3. International Council of Nurses. (2010). Violence: A worldwide epidemic. Retrieved from http://www.icn.ch/images/%20stories/documents/publications/fact_sheets/19k_FS-‐Violence.pdf 4. International Labour Office/International Council of Nurses/World Health Organization/Public Services International. (2003).Workplace violence in the health sector country case studies research instruments-‐research protocol. Geneva, Switzerland: ILO/ICN/WHO/PSI Joint Programme on Workplace Violence in the Health Sector. 2389 Working Around ‘The Clocks’: Nurses’ Responses To Electronic Overdue Medication Alerts Deborah Debono1, David Greenfield* 1, Deborah Black2, Jeffrey Braithwaite1 1 Australian Institute of Health Innovation, University of New South Wales, 2Faculty of Health Sciences, University of Sydney, Sydney, Australia Objectives: Electronic Medication Management Systems (EMMS) have an ‘Overdue Medication Alert (OMA) function’ designed to improve governance, quality and safety of patient care. We know relatively little about the impact of the OMA feature on the medication administration process, and how it affects nurses’ work. This study seeks to address this issue. Methods: The study was conducted in 2011 in an Australian metropolitan teaching hospital. We conducted interviews (n=27) and four focus groups (n=17) with nurses in three wards. Participants described their experiences of and responses to the EMMS OMA feature, represented by a clock icon. Interviews were recorded, transcribed and data were analysed thematically. Results: Participants reported that the OMAs promoted explicit and visible monitoring of themselves and their colleagues. OMAs made completed medication work visible to an audience locally and across the hospital. The impact of the perceived monitoring was determined by the role of the individual and the ward culture. Nurses used OMAs to monitor and support their own practice, e.g. as a reminder of medication administrations to be completed, and as prompts during individual shift-‐to-‐shift handover to communicate unfinished work. OMAs also created anxiety, with participants suggesting that ‘the clocks’ represented that their day was ‘falling apart’. Participants in senior roles used the OMAs as an unobtrusive and non-‐personal monitoring method to check their colleagues’ medication administration progress. Differences in nursing teams’ collective response to OMAs were influenced by ward culture. OMAs were described as expected given the competing demands on nurses’ time. Participants highlighted that OMAs provided opportunities to identify when colleagues needed help. However, while cognisant that late medications could be attributed to a number of factors, including high workload and deteriorating patients, other participants raised concerns. The concerns included that OMAs, visible to their colleagues, may be interpreted as laziness, poor time management, not coping, or not caring about their patients. In response, some participants reported using workarounds, rushing medication rounds, or focusing on medication administration over other patient care to avoid or remove OMAs. Conclusion: OMAs make completion of medication work an outcome measure visible to a wide audience, the interpretation of which is mediated by ward culture. OMAs promote a collective mind-‐set, allowing nurses to monitor, compare and contrast their own and colleagues’ work. Whether this supports or undermines individuals, teams and patient safety is partly determined by ward culture. OMAs can enhance patient safety when used as a reminder or alert that medications have not been administered. They also provide opportunities to identify nurses who may require assistance. However, the visibility of OMAs to a wide audience and the perceived link between OMAs and practice, can shape nurses’ work in ways that undermine patient safety and quality. Making outcome measures, such as completed medication tasks, visible, changes the process by which care is delivered. To realise the benefits of making work visible, organisations must attend to local context and cultural workplace issues. Governance strategies are needed that promote a shared understanding of the: intended purpose; unpredictable demands of clinical work; importance of teamwork; and potential effects of hidden workarounds. More broadly, the study highlights the implications of technology that prioritises outcome measures rather than the processes by which these are achieved. 2412 Satisfaction Of Mothers With Childcare Services Provided At Public Institutions In Japan: The Association Of Socio-‐Economic Factors Eri Ishikawa* 1, Shoichi Maeda2, Jay Starkey 2 1 Faculty of Nursing & Medical Care, Department of Community-‐Public Health Nursing , 2Medical Ethics & Patient Safety Laboratory, Keio Research Institute at SFC, Keio University, Fujisawa Kanagawa , Japan Objectives: Background: In Japan, as elsewhere, various childcare services are offered in public institutions. The satisfaction of mothers in particular who utilise these services is important to determining how such services could be improved as mothers are primarily responsible for selecting and evaluating such care. As such, mother satisfaction surveys have been previously completed. However, no detailed studies of how socioeconomic factors are associated have been completed. While some studies have included so-‐called “socioeconomic data,” this has been only little more than household income without deeper analysis of how such data relate to satisfaction. Objective: To explore the associations of socioeconomic factors with the satisfaction of mothers with toddlers who public utilise childcare services. Methods: Participants: All mothers (n=2464) with children 1-‐3 years of age living Ikuno-‐ku (103,329 residents), Osaka, the second largest city in Japan. An anonymised self-‐administered postal questionnaire survey was conducted in October 2011. Questions were asked about participant’s Socio-‐Economic Status (SES), including 8 items such as household income, mother’s educational background, budget, Subjective Social Status (SSS), and others and a 5-‐point Likert-‐type satisfaction scale regarding childcare services provided public institutions (1 dissatisfied, 5 very satisfied). SPSS Statistics 21 was used for the statistical analysis of the data. Chi-‐square tests or Direct Fisher tests were used to assess the associations between the sets of the relevant results. Results: The response rate was 47.9%. The mother’s income, budget, and SSS were significantly associated with satisfaction. Mothers or fathers educational level; household income, welfare, and mother’s occupation were not significantly associated with the satisfaction. Conclusion: 3 of 8 factors investigated were significantly correlated with higher satisfaction. This suggests that any analysis of satisfaction with public childcare services needs to be performed while accounting for socio-‐economic status. Likewise, attempts to determine how to improve such services also need to consider socioeconomic status. 2478 Awareness And Improvement Of Patient Safety Culture In A Newly Established Local Community Hospital Using The Questionnaire From SAQ And AHRQ Li-‐Wen Hung* 1, Yen-‐Ying Ma2 1 Medical Quality Control Division, 2Department of Obstetrics and Gynaecology, Chang Gung Memorial Hospital, Yunlin, Mailiao Township, Yunlin County, Taiwan Objectives: To investigate and promote patient safety attitudes of hospital employees in a newly established local community hospital. Methods: To study patient safety culture of employees in our hospital, we participated in national Patient Safety Culture Survey held by Taiwan Joint Commission on Hospital Accreditation in 2012 and 2013, respectively. Our colleagues answered cross-‐sectional questionnaires online to express the level of satisfaction for 41 items of patient safety questions in six aspects from SAQ (Safety Attitudes Questionnaire) developed by the University of Texas and three aspects from AHRQ (Agency for Healthcare Research and Quality, USA). We invited a full-‐time expert practitioner for patient safety to propose a detailed promotion policy according to the statistics data analysed by independent sample t test. Results: A total of 74 questionnaires were proved to be valid in 2012 and 116 questionnaires were valid in 2013. Analysis of questionnaires in 2012 revealed the patient safety attitudes in our hospital were far worse than average in eight of nine aspects (except for stress recognition), compared to either academic medical centers, metropolitan hospitals, or other local community hospitals. Thus we executed an improving plan in five dimensions step by step, including medical quality monitoring, patient safety work, quality improvement competition, projects to improve matters, and education training. The statistics data in 2013 showed significant improvement in six aspects which were teamwork climate (p<0.05), safety climate (p<0.05), perception of management (p<0.01), working condition (p<0.01), support by administrators (p<0.05), and cooperation of cross-‐section units (p<0.05). Our overall patient safety attitudes in 2013 were compatible with other local community hospitals in Taiwan. However, stress recognition of hospital staff in 2013 showed unexpected negative changes after aggressive intervention, which needs further evaluation. Conclusion: The questionnaire from SAQ and AHRQ is a useful tool to expose underlying problems of patient safety culture in our hospital. The following correcting plan seems to be crucial to improve patient safety attitudes of hospital staff and to reduce the probability of adverse events or errors. Keywords: patient safety, questionnaire Abbreviations: SAQ (Safety Attitudes Questionnaire); AHRQ (Agency for Healthcare Research and Quality) 2525 Using Risk Scores To Identify Vulnerable Populations: A Case For LDL Cholesterol Ronit Calderon-‐Margalit* 1, Dena Jaffe1, Orly Manor1 1 Hadassah-‐Hebrew University Braun School of Public Health, Jerusalem, Israel Objectives: The Adult Treatment Panel III (ATP III) guidelines for target levels of LDL-‐cholesterol according to risk stratification were published in 2002 and, thereafter, widely accepted. Accordingly, LDL-‐cholesterol goals by risk for coronary heart disease (CHD) events are <160mg/dl, <130 mg/dl, and <100 mg/dl for low, intermediate, and high risk patients, respectively. The Israel National Program for Quality Indicators in Community Healthcare (QICH) has collected data annually since 2002 for the entire Israeli population using electronic health records. Intermediate outcome measures were used to assess primary and tertiary preventive care for the general adult population and patients with diabetes or CHD. Up until 2012, a single outcome measure (LDL-‐C<160 mg/dl) was used as a primary prevention measure in addition to LDL-‐C<100 mg/dl among patients with either diabetes mellitus (DM) or CHD. In 2012, QICH updated these outcome measures to reflect the ATP III guidelines. Objectives: To examine the impact of risk stratification on LDL control measures. Methods: The Framingham risk score of cardiac morbidity was calculated for adults aged 35-‐74 years, who were not identified as having either DM or CHD. Individuals were stratified into low risk (0-‐1 risk factors), intermediate risk (>2 risk factors and 10-‐year CHD risk <20%), or high risk (10-‐year CHD risk ≥20%, DM or CHD). The proportion of each stratum achieving the appropriate LDL-‐C goals was calculated. The high-‐risk stratum was assessed according to primary prevention or by disease risk group (DM or CHD). Results: In 2012, the target population for primary prevention of CHD included 1,035,351 individuals aged 35-‐74; 92% of this population had LDL-‐C levels below 160 mg/dl, the former target of the QICH program. Of the 739,110 individuals with low risk of CHD, 91% have reached the <160 mg/dl goal. Of the 279,210 individuals with intermediate risk, 72% have reached the <130 mg/dl goal. Only 18% of the 17031 high risk individuals reached the <100mg/dl goal. This rate is much lower than the target achieving rate among other tertiary prevention high risk groups; among patients with documented CHD, 72% had LDL-‐C levels below 100 mg/dl. Similarly, among patients with DM, 63% have reached this goal. These rates among CHD and DM patients have increased throughout the QICH program period and have reached a plateau around 2008. Conclusion: While a single outcome measures reflected the majority of the population, it missed the critical minority who needs attention. Risk stratification should be used whenever possible. It remains to be studied whether identifying these high risk patients will improve their outcomes in the years to come. 1149 The Effect Of Government Supervision On Quality Of Integrated Care And Diabetes Type 2 Health Outcomes: A Cluster Randomised Controlled Trial SF Oude Wesselink* 1, HF Lingsma1, JP Mackenbach1, PBM Robben2, 3 1 Public Health, Erasmus MC, Rotterdam, 2Dutch Health Care Inspectorate, Utrecht, 3Institute of Health Policy & Management, Erasmus University, Rotterdam, Netherlands Objectives: Effect of government supervision on quality of care and patients’ health is seldom studied. This study aims to evaluate the effect of government supervision on care groups providing integrated diabetes care, on quality of care and health outcomes of patients. Methods: In this cluster randomised controlled trial supervision was randomly assigned to care groups who provide care to diabetes patients. Care groups consist of 5 to 100 general practices, which are paid with bundled payment. Supervision was executed by the Dutch Health Care Inspectorate and included announcements of inspections, site visits and sending personal reports. Primary outcomes were structure, process and health outcome indicators and were collected from patient files, before and after intervention. Structure and process indicators were aggregated into sum scores, ranging from 0 to 11 points. Data of 18 care groups from 356 patients (180 intervention, 176 control) were analysed with hierarchical linear and logistic regression models. Results: No differences in structure, process or outcome indicators between the intervention and control group were found. However, the total population of intervention and control practices showed an improvement over time in structures of care, the structure score improved with almost 1 point (p=0.00). The process score increased with 0.26 points (p=0.38) over time, but no improvements in patient outcomes were found over time. Conclusion: No effects of government supervision on care groups providing integrated diabetes care are found. Since all care groups improved structures of care, it remains possible that the supervisory activities led to improvement in quality of care of all care groups. Patient outcomes did not improve over time. 1234 Hospital Mortality In Selected Brazilian Hospitals: Do Primary Payer Status And Public-‐Private Partnerships For Financing Hospitals Affect Quality? Juliana Machado* 1, Monica Martins2, Iuri Leite3 1 Information Production, National Regulatory Agency for Private Health Insurance and Plans, 2Health Planning and Administration, 3Epidemiology, Fiocruz, Rio de Janeiro, Brazil Objectives: Considering the public-‐private mix in the Brazilian health sector, where almost 30% of the population is covered by private health insurance, and hospitals can provide care both for private insured and public insured populations, in this study we aim to examine whether hospital quality, as measured by risk-‐adjusted mortality rates, differs according to the patient insurance status and to the hospital public-‐private partnerships in its financing. Methods: Our analysis was based on pooled 2008-‐10 National Inpatient Database records of hospital discharges, in the public and private sectors, from hospitals located at the states of São Paulo and Rio Grande do Sul. They were selected because of their database quality, the diverse private insurance coverage and diverse supply of hospitals beds. They contain 27% of the nation’s population and the same of the nation’s discharges. Patients were included in the analysis if the primary diagnosis was one of those which accounted for 80% of hospital deaths. Variables used for risk adjustment of mortality were: sex, age, severity measures based on co-‐morbidity and principal diagnosis, use of ICU and type of procedure. A logistic regression was used to test the hypothesis that quality differs according to the patient insurance status and to the hospital public-‐private partnerships in its financing. Hospitals were classified as low or high outliers according to the ratio between observed and expected hospital mortality rates. Results: The risk-‐adjustment model was considered to have a reasonable discriminative value under c statistic (c = 0.79). Privately insured patients had lower risk-‐adjusted mortality rates than did SUS patients. Clinical performance in private not for profit hospitals as measured by adjusted hospital mortality was better than in public or private for profit hospitals. Hospitals that provide care both for private insurance companies and SUS was better than those that exclusively provide care for SUS or for private insurance companies. Overall hospital mortality rate was 5.99%. The rate was 1.51% among patients treated in the low outliers and 9.34% among the high outliers. Conclusion: Although some problems related to the completeness of the Brazilian databases, the method to select discharges used in this study showed a better discriminative power than other methods using specific diagnosis or procedures. It suggests that hospital mortality and other adjusted performance indicators should be seriously considered as useful tools to identify health services’ performance problems in the country. The relationship between better quality and variability of financing sources has to be explored in order to identify specific management factors leading to this result. The differences according to patient insurance status denote that to help reduce care disparities, public authorities and hospitals managers should measure care quality for different groups and monitor differences in treatment practices within hospitals. 1881 São Camilo Hospital Score For Predicting The Long Term Hospital Marcelo R. D. A. Sartori* 1, Renato J. Vieira1, Fabio L. Peterlini1 1 Sao Camilo Hospital, Sao Paulo, Brazil Objectives: This study aims to develop a score able to predict, at hospital admission which patients are at risk of hospitalisation exceeding 15 days. Methods: A quantitative descriptive study. To construct the model we used the database of all hospital entrances, between 01/01/13 and 28/02/13, initially relying on 5,962 patients. Due to historical chronicity of the institution to be bound by the emergency entrance and clinical specialties, we chose to focus the study only on deriving clinical patients in the Emergency Room Adult, excluding surgical admissions. Of the 2,116 patients who made up this profile, we selected the 1,861 patients whose first sector of hospitalisation was not the intensive care unit, once for our analysis the classification Care (Fugulin´s) was one of the items analysed on the first day of hospitalisation. The base studied in the begin was 1,840 admissions representing the arrivals coming from the emergency services of the São Camilo Network, which were allocated to the inpatient units in clinical specialties and who had all studied risk correctly filled in the system. These patients had the following data were analysed: hospital stay, previous hospitalisation within the past 30 days, reason for discharge, sex, age and risks of phlebitis, pulmonary aspiration, isolation, TEV, Fall, Braden Scale and Fugulin classification. After developing the model, we tested the score in hospitalised patients during the period 01/03/13 to 31/03/13, this time comprised 980 patients admitted to clinical specialties from the First Aid Station -‐ Adult that had all its risks analysed on the first day of hospitalisation. Results: In the first regression model of the variable time of permanence front of all the other predictor variables, showed that only the presence of previous hospitalisation in the past 30 days did not reach statistical significance being gender (p = 0.01), previous hospitalisation (p = 0.38), risk of phlebitis (p < 0.001), risk of aspiration (p < 0.001), indicating isolation (p < 0.001), risk of VTE (p = 0.004), Fugulin classification (p < 0.001), fall risk (p < 0.001), Braden classification (p < 0.001) and age (p = 0.03). According to the intention of obtaining a simplified model, the variables: previous hospitalisation, age, sex, risk for VTE, risk for aspiration and Braden were sequentially excluded, resulting in a four predictors variables model: Risk for phlebitis, Isolation, Classification Care and Risk of Falling. The score when applied to the first population showed sensitivity, specificity, Positive Predictive Value ( PPV) and Negative Predictive Value (NPV) respectively 72.4%, 82.9%, 44.3% and 94.1%, while in the second population yielded sensitivity, specificity, PPV and NPV respectively 60.6%, 85.4%, 41.3% and 92.7%. Conclusion: The data suggest that the systematic analysis of health care risks of falls, phlebitis, statement isolation and classification of care evaluated on the first day of hospitalisation may provide important information for predicting possible chronic or high hospitalisation. The score developed demonstrated robust performance in care reality of the São Camilo Hospitals network. Whereas the phenomenon measured (length of stay) is absolutely inseparable from the care performance and treatment options of each institution, still cannot be said that the performance observed here resist other care scenarios, due validation is required. 2114 The Impact Of The Management Of Beds Based On Lean Six Sigma Methodology Ana L. D. Geloneze* 1, Monica D. S. B. Pinheiro2, Nidia L. N. Bittencourt3, Paulo A. D. M. Junior4 1 Quality Management, 2Medical Management, 3Nurse Management, 4IT Management, Hospital Estadual Sapopemba -‐ Seconci -‐ OSS, Sao Paulo, Brazil Objectives: Description of the results and impacts achieved through changes promoted in the management of hospital beds, based on Lean Six Sigma Methodology. Methods: In September 2013 an analysis of the general situation of the management of hospital beds was conducted through the measurement of the period between hospital discharges and effective vacancy of beds. Therefore, the researchers have investigated the periods, which beds remained idle. The analysis has found an average 5 hours of idleness in hospital beds. Through Lean Six Sigma methodology, we mapped the whole process of management of beds in order to identify major gaps and point out corrective measures. The idle time of beds designated for surgical clinic was 10 hours, followed by medical clinic 6 hours, and paediatrics and motherhood both with 2 hours. Due to that, initially we decide to restrict the scope of the project and concentrate only on surgical clinic as a pilot study and then expand to the entire hospital. The measures proposed were: 1. 2. 3. 4. At the moment of the patient's admission at the hospital, the doctor should register the expected date of discharge. The nurse unit should confirm the date with the doctor 24 hours before the expected date of discharge. All professionals involved in this process are reported and all the necessary arrangements are finalised. On the day of discharge, the doctor must finalise the process early in the morning. From this moment, the nurse team haves up to 1 hour to complete their actions and thus promote the eviction of the bed. 5. Once the bed is unoccupied, the professionals who sanitise has up to 1 hour to sanitise and make this bed available to the central vacancies sector. All these steps are monitored by an electronic system. In order to obtain these results, categorical variables were tested with Chi-‐square test, Wilcoxon test and Kolmogorov-‐Smirnov test. Results: We have observed a significant reduction in idle time in the beds of the surgical clinic. After four months of the implementation of corrective actions, the average idle time of the surgery clinic beds decreased from 10 hours to 3 hours (p<0,001). All professionals involved in this project came to understand the importance of integrated management, teamwork and how the communication between the various teams involved in the process is fundamental. The daily rate in the surgical clinic = US$ 211, hour value in the surgical clinic = US$ 8.81. With idle time of 10 hours, there is a loss of US$ 31.723 per year. With the reduction of the average idle time of the bed to 3 hours, there has been a reduction of losses to US$ 9.516 per year. Considering that the project was only conducted at the surgical clinic and will be expanded to the entire hospital on March 2014. Conclusion: All professionals involved in this project came to understand the importance of integrated management, teamwork and how the communication between the various teams involved in the process is fundamental. When sectors work independently, the results achieved are less positive. The management of beds should always work seamlessly with various professionals involved. References: 1. Roberto G. Rotondaro. Six Sigma Management strategy to improve processes, products and services. São Paulo. Atlas Publisher. 2013. 2332 Pharmacist Presence In National Health System Hospital Network In The State Of Rio De Janeiro Milton D. L. Filho* 1, Aline A. Costa1, Monique A. Brito1, Rachel Magarinos-‐Torres1 1 College of pharmacy,, Fluminense Federal University -‐ Niterói / RJ, Brazil, Rio de Janeiro, Brazil Objectives: The increase in drug spending and the need to ensure access and rational use of this demonstrates the importance of the pharmacist inclusion in health care team. The pharmacy service is responsible for various activities with strong impact on hospital care and quality of services has close ties with the performance of this professional. This study aimed to verify the participation of pharmacists in National Health System (NHS) hospital network in the State of Rio de Janeiro. Methods: Data were collected from the National Registry of Health from August to October 2013. Pharmaceutical distribution was studied according to the health care area, size, level of complexity and type of hospital administration. It was also verified the number of hospital beds per pharmacist. Results: The State of Rio de Janeiro is composed by 92 municipalities with a population of about 16 million inhabitants distributed in 9 health regions. 268 hospitals that provided 26,571 beds to the NHS were identified. The number of pharmacists working in the hospital network is 1,408 and most are concentrated in the Metropolitan i and ii regions (79.2%). It was observed that 9.7% of these establishments have no pharmacist in charge, particularly in three regions: Mid-‐South (n = 6, 31.6%), Coastal Lowlands (n = 6, 28.6%) and Metropolitan ii (n = 6, 18.8%). Only in the North were not found hospitals without pharmacist. In all regions it was observed a predominance of pharmacists in institutions with general profile (64.8%), even in the Metropolitan i region, which shows the highest percentage of specialised hospitals (52.2%). Regarding the distribution of these professionals by hospital size, 48.2% work in mid-‐size hospitals, 39.6% in large hospitals and 12.2% in small hospitals, which is consistent with the predominance of medium-‐sized institutions in 8 of 9 health regions. In all regions dominated professionals in hospitals higher level of complexity (level 8), which seems to be explained by the increased need for professionals in these institutions due to the greater complexity of pharmaceutical services, as well as the fact that most hospitals have complexity level 8 (57.1 %). Regarding the type of hospital administration, 82.8% of pharmacists work in public institutions, leveraged by the Metropolitan i region, with 91.9% of professionals in public administration. The ratio of hospital beds per pharmacist revealed state average of 21.3 beds/pharmacist, ranging from 82.32 in Mid-‐South region to 14.83 in Metropolitan i region, which has the highest number of professionals by hospital. According to the Brazilian Society of Hospital Pharmacists more than 50 hospital beds per pharmacist represents an overload of the pharmacy service and compromises the quality of care, which can be observed in three health regions: Mid-‐South, Mountain and Middle-‐Paraíba. Conclusion: The growing demand for more effective health services, as well as the rational use of medicines, cost reduction, minimisation of drug-‐related problems and improve safety of pharmacotherapy point to the need for public policies that encourage and prioritise measures that guarantee the effective presence of the pharmacist in hospitals. 2499 Practical Implementation Of A Clinical Case In The Selection Of Nursing Technicians Anelise J. Barretto* 1, 2, Deborah Rozencwajg2, Renata F. Ganem2, Daisy M. S. Okada2 1 Select Program Development and Retention of Newly Graduated, Hospital Israelita Albert Einstein, 2Select Program Development and Retention of Newly Graduated, Hospital Albert Einstein, São Paulo, Brazil Objectives: To present a realistic model for a selective process of technical nursing simulation. Methods: A quantitative, retrospective, level I performed in a general private hospital in São Paulo, in the period July 2013 with a population of 135 newly trained technicians study nursing . The structuring of the action took place in five stages: a) written development of clinical case with a real situation with specific theoretical content of the topic approach, b) preparation of candidate assessment tool, c) preparing the stage for implementation of the case; d) dynamic presentation for the realistic simulation of the candidate. And "Feedback evaluator / observer" to the failed candidate encompassing information helpers in the development plan. Results: The Moment A -‐ Prepared two cases related to a patient with urinary tract infection antibiotic should be administered orally; Moment B -‐ The evaluation instrument consisted of a "check -‐list " of ten items related to step-‐by-‐step in the medication administration process orally; Moment C -‐ Organised two scenarios in a room of patient care where there was an assessor/observer , a bed with a character who pretended to be a patient -‐specific materials such as prescription of patient medications orally identified with dose, trade name and chemical drug, a pharmaceutical manual and materials for the process of medication administration; Moment D -‐ Directed individual reading of the clinical case fixed on the door to 135 candidates and presented the scenario with permission recognition materials during the period of five minutes before starting the evaluation; Moment E-‐ done five feedbacks requested by the assessor failed with/observer involving candidate: Approach of the scientific reasoning during the scenario process of drug administration, clinical reasoning, technical skill, attitude and interaction with the patient during realistic, simulation and registration initiative being emphasised to the candidate's strengths and points for improvement for next selection process . Conclusion: The creation of a realistic simulation model for a selective process technicians nursing graduates admitted to a large hospital requires much effort, since the preparation of a case for the practical implementation of the applicant to obtain data showing the effectiveness, accuracy, and data consolidation observed in the evaluation of the candidate and feedback quality . In our experience, the stage of practical evaluation of the candidate simulating a real situation the bedside grounded in theoretical knowledge and practical procedures is an advantage for the selection process of newly formed candidate factor and contributes to opportunities for observation and sometimes orientation for improving actions do not conform to the quality of hospital care these professionals for the future. 2514 Development Program Nurse -‐ The Challenge Of Attracting The Best Professional Regiane P. Santos1, Deborah Rozencwajg1, Daisy M. S. Okada* 1, Michele A. Mendrot1 1 Select Program Development and Retention of Newly Graduated, Hospital Albert Einstein, São Paulo, Brazil Objectives: To review the Selection Program Development and Retention of Nurses newly formed through headcount indicators, turnover and utilisation of a Junior Nurse in Internal Recruitment (IR). Methods: A descriptive and quantitative Selection Program, development and retention of new nurses graduated in a General Hospital of highly complexity located in São Paulo -‐ Brazil, with a capacity of 617 beds. Results: In 2012, 53% of the vacancies of Junior Nursery were closed with IR and 47% students from the Nursery College of the Albert Einstein Institute and the Improvement Program. Of this total, 54% were promoted with less than one year; this is due to a selective process focused on institutional competencies defined by the Nursery Centre. Through a committee with people from different areas, actions improvements were implemented: review of criteria to support policy finance, structured feedback to professionals and not approved in IR enlargement of the Improvement Program. Conclusion: The program must be robust in order to sustain the selection, development and retention of professionals, provide internal opportunities for newly qualified nurses, allow career progression for both assistants and nursing technicians and encourage professionals from other areas to join the profession. Investing in newly formed nurses bringing benefits for the institution, which reinforces its image marketing excellence for the patient who is assisted with quality and safety and for the professional who has the opportunity to develop and improve at one of the Best Companies to Work. 2511 The Presence Of Nurses In The Management Of Beds In The Admission Patients Area Luiz F. Moreira1, Juliana T. Vasconcelos* 1, Adriana M. Alexandridis1, Regiane P. Santos1 1 Admission Patients Area, Hospital Albert Einstein, São Paulo, Brazil Objectives: To present the management of the hospital beds in the presence of nurses. Methods: Descriptive, retrospective, exploratory, level 1, quantitative conducted in the inpatient unit of a general private hospital in the city of São Paulo in the period January 2013 to September 2013. The data on the proper allocation of the patient in the art were collected through informed in a database of Information Technology which consists of the total patient-‐ days allocated in the art and through a worksheet where we raise the time of requesting system bed inserted by administrative technician at admission of the patient and the time of booking the bed achieved by control officers beds to patients hospitalised for elective procedures. In case of Emergency Room (ER) shows the time of requesting the bed made by administrative technician at the time of admission of the patient and the time of booking the bed achieved by control officers beds, On the Adult Intensive Care Unit (AICU) raised in a spreadsheet, the schedule released by the High administrative Technician registry of ICU and time of booking in the bed Medical Surgical Clinic (MSC) held by control officers beds. Results: The goal for proper allocation of the patient in the specialty was 91% and found that the percentage achieved during the nine-‐month period was equivalent to 89.0%, but there was relevance in a month in this period, with the goal to achieve the time average waiting elective beds was 18 minutes and observed for nine months the average achieved was 16 minutes showing that only two months did not reach the planned target; regarding the goal to be achieved for the average waiting time for beds in the ER was 60 minutes and observed an average for nine months of 66 minutes, so we had two months to reach the proposed goal; on the ICU goal for the waiting time for bed transfer MSC was four hours and reached an average equivalent in nine months two hours and seventeen minutes meaning a significant reduction in waiting time for patients to transfer between ICU and MSC. Conclusion: We noted that the presence of the nurse in patient hospitalisation process was fundamental for a correct allocation in the art; facilitated to improve the waiting time in the transfer of patients between ICU enabling MSC for their assistance with the vision of the hospitalisation process, the satisfaction of the internal and external customer. 1182 Strategies To Facilitate Implementation And Sustainability Of Large System Transformations: A Case Study Of A National Program For Improving Quality Of Care For Older People Monica E. Nyström* 1, 2, Helena Strehlenert1, Johan Hansson1, Henna Hasson1 1 Dep. of Learning, Informatics, Management, and Ethics (LIME), Medical Management Centre, Karolinska Institutet, Stockholm, 2Dep. of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden Objectives: Large-‐scale change initiatives stimulating change in several organisational systems in the health and social care sector are challenging to lead and evaluate. There is a lack of systematic research that can enrich our understanding of strategies to facilitate large system transformations in these sectors. The purpose of this study was to examine the characteristics of strategies to facilitate implementation, core program activities, and outcomes of a national program for improving life for the most ill older people in Sweden. Methods: A longitudinal case study design with multiple data collection methods was applied. Archival data (n=795), interviews with key stakeholders (n=11) and non-‐participant observations (n=23) were analysed using content analysis. Outcome data (frequencies and proportions) was obtained from national quality registers. Results: This study presents an approach for implementing a large national change program that is characterised by initial flexibility and dynamism regarding content and facilitation strategies and a growing complexity over time that required more structure and co-‐ordination. The description of activities and strategies show that the program management team dealt with many types of stakeholders and actor groups and accordingly used a palate of different strategies. The use of regional improvement coaches, regional strategic management teams, national quality registers, financial incentives and yearly updated agreements were the main strategies used to influence change in the target organisations. These were complemented by interactive learning sessions, intense communication, monitor and measurements, and active involvement of different experts and stakeholders, including older people. Altogether, we identified ten strategies that was used by the program management to facilitate implementation and change. Program outcomes showed steady progress in most of the five program target areas, less so for the target of integrated care. Conclusion: There is no blue-‐print on how to approach the challenging task of leading large scale change programs in complex contexts, but our conclusion is that more attention is needed to the multi-‐dimensional strategies that program management need to consider. This multi-‐dimensionality comprises different strategies depending on types of actors, system levels, contextual factors, program progress over time, the program content, types of learning and change processes, and the conditions for sustainability. 1192 Limited Effect Of Information Technology Support To Improve Handover From Hospital To Primary Health Care Peter Qvist* 1 1 Region of Southern Denmark, Centre for Quality, Middelfart, Denmark Objectives: To assess the effect of implementing rapid and timely information exchange between hospital and primary health care to prepare for discharge of elderly vulnerable patients. Methods: In the Region of Southern Denmark IT solutions for rapid and timely exchange of information between hospitals and primary care for in-‐hospital patients have been implemented during the past few years. The aim of the initiative has been to provide the local communities with relevant health related information for vulnerable patients needing follow up after discharge. The usefulness of the electronic information exchange was evaluated by collecting data from IT correspondences between all five hospital units in the region and 20 local communities. Data concerning the content and usefulness of correspondence messages from community nurses to hospital departments were assessed by hospital nurses and vice versa. Registered variables included presence or absence of a range of information including diagnoses, treatment, medication, physical, mental and social status, need for personal aids and daily care support, nutrition and housing situation. Relevant hospital departments were asked to include 40 randomly selected vulnerable patients, each community to include 10 randomly selected vulnerable patients. Results: Correspondence messages from communities to hospitals concerning 192 in-‐hospital patients were included and evaluated. For the vast majority of patients, the timeliness of correspondences matched expectations and agreed standards. In only 37 % of cases, the hospital nurses found the content of the information from the community sufficient to act upon in relation to the patient’s hospital stay and discharge. Insufficient information was primarily related to physical and mental status and daily care needs including nutrition. Evaluation of correspondence messages from hospital to communities were based on 168 included patients. 42% of initial messages were delayed compared to agreed standards. For 35% of patients the initial message was rated as insufficient. For 68% of patients the community nurses found it necessary to request further information before handover of the patient at the time of discharge. Feedback from both communities and hospital departments pointed out the following reasons for the unsatisfactory results of the evaluation: 1) Limited education and experience between staff members in concise written correspondence. 2) Insufficient documentation in hospital and community case records. 3) Insufficient time to collect and forward the information. 4) Failure to meet the expectation from the opposite party regarding the content of the information. Conclusion: This study shows that the development of IT solutions to support effective handover of elderly frail patients should be supplemented with other initiatives such as improvement of case record documentation in both communities and hospitals, education of staff in concise written information exchange and alignment of mutual expectations in terms of the content of the electronic correspondence. 1436 Have You SCAND MMe Please? To Prevent Harm In Older Emergency Medical Admissions To Acute Hospitals Bernice Redley* 1 1 Scool of Nursing and Midwifery, Epworth Deakin Centre for Clinical Nursing Research, Deakin University, Richmond, Australia Objectives: The mnemonic ”SCAND MMe Please” (Skin-‐integrity, Continence, Assessment for medical risks, Nutrition, Depression, delirium and dementia (cognition), Mobility, Medications and Pain) has was derived from best available evidence of factors known to contribute to preventable harms of hospitalisation for older patients in acute care. The mnemonic complements the domains of care in the evidence based policy ‘Best care for older people everywhere -‐ The toolkit’. [1] Introduced to Australian hospitals in 2009. The objective of this study was to use the mnemonic to evaluate the policy implementation in terms of 1) implementation strategies and 2) documentation of risks and strategies used to mitigate preventable harms during acute hospitalisation of older emergency medical patients in public and private health services. Methods: An exploratory descriptive mixed method research design combined data on health service operations and clinician work practices with patient outcome measures extracted from medical records. The study was conducted in two parts. In Part 1, a retrospective audit of the medical records of 400 emergency medical separations, randomly selected over one year, at four different acute hospital sites representing public and private, large and small, metropolitan and regional hospitals. In Part 2, interviews with over 20 key stakeholders at the same four acute hospital sites were used to evaluate local implementation strategies to mitigate risks of preventable harm in older emergency medical admissions. Results: Analyses are ongoing. This abstract includes only key findings that emerged from preliminary analysis. The presentation will be supported by data. Analyses of qualitative focus data using a framework of clinical microsystems revealed the wide range of strategies successfully used by health services to implement harm minimisation for older emergency admissions. Gaps emerged related to recognition of all risks denoted by the mnemonic (e.g. pain), the use of validated tools, monitoring and integration into frontline clinical governance. Analyses of medical record audit data revealed significant gaps related to documentation in all elements of risks for harm; particularly assessments, the frequency of re-‐ assessment, response to identified risks and success of interventions used. Conclusion: The mnemonic “SCAND MMe Please” was a useful tool to guide evaluation of the policy implementation and has potential for wider application. Analyses reveal gaps in the implementation of harm minimisation strategies for older patients in acute hospitals relate to use of validated tools, poor documentation practices and pain management. The outcomes of this research provide a useful tool and baseline data to examine the effects of introducing the mnemonic as a memory aid to assist clinicians avoid harms of hospitalisation for older emergency medical admissions in acute hospitals. References: [1] See http://www.health.vic.gov.au/older/toolkit/ 2262 Using Action Research To Promote Compliance With Health Examination For Rural Residents Li-‐Chin Tsai* 1, Tung-‐Jung Huang1, Wei Hsu Chih1, Mei-‐Yen Chen1 1 Chang Gung Memorial Hospital, Yunlin, Taiwan Objectives: There is an urban-‐rural gap in health care resource in Taiwan. Other than aging issue, the residents in Yunlin County are also facing health problems, such as higher prevalence rate of tobacco and alcohol consuming and betel nuts chewing. According to 2011 Yunlin County statistics, the residents of coastal areas had higher mortality of liver and intrahepatic bile ducts cancer, oral cavity cancer, and oesophageal cancer and higher prevalence rate of hypertension and hyperlipidaemia than the residents of non-‐coastal areas. To “early detection and early intervention” in order to disease prevention, it is important to increase the compliance with health examination of rural residents. Methods: Using the action research model by Kemmis and McTaggart (1982) as conceptual framework, a total of 3,732 rural residents from Taixi Township, Yunlin County, Taiwan were recruited from November 15, 2012 to January 27, 2013. The results from the survey showed that the main reasons for the low compliance rate of health examination for rural residents included: (1) (2) (3) (4) lack of belief in prevention, lack of public advertisement, inconvenient of public transportation, and long waiting time. There were four action strategies designed including: 1. 2. 3. 4. holding educational preventive instruments in communities, using diverse public advertisement, using designate transportation for health service, and setting Standard Operating Procedure (SOP) of health examination. Results: Through action strategies of “understanding” and “change”, the results of this action research showed: (1) Numbers of the rural residents receiving health examination increased from 8,081 to 12,348. The health examination rates increased from 12.3% to 18.8%. (2) The satisfaction level of rural residents who received health examination was 88.0%. It show that this action research can effectively increase the compliance rate of health examination for the rural residents from Taixi Township, Yunlin County, Taiwan. Conclusion: This action research has helped in building an equal partnership and collaborative relationship between the researchers and rural residents. Through solving practical problems, the rural residents could gain knowledge and hence change behaviour via practical process. After understanding the needs of the residents, this action research designed and utilised innovative and practical action strategies to promote their participation in health examination. It is suggested to continue these action strategies to early detection and early intervention. Keywords: action research, rural areas, health examination/checks, compliance 2321 The Quality Standards For Health Care Services Provided In Turkey Reyhan Ozgobek* 1, Aylin Çiftçi1 1 Ministry Of Family And Social Policy, Ankara, Turkey Objectives: Long Term Health Care services include provision of personal care services for sick, elderly and disabled individuals, the performance of their activities of daily living and the treatment for health care support purposes. Methods: The efforts for improving health care services and the service quality are also carried out in Turkey where the population is relatively young in comparison with the other countries so as the other countries. As a result of the increasing necessity, the efforts for improving service and workforce quality in order to provide good quality services to both the citizens who live in abroad and the individuals who want to obtain care services in Turkey have become more important. The studies of Quality Standards for Care Services provided in Turkey are examined and it is referred to the resources of the General Directorate of Services for Persons with Disabilities and Elderly People-‐that carries out the studies in this field and affiliated to the Ministry of Family and Social Policy. As the studies accelerated in 2013, they are jointly carried out together with the Department of Quality Improvement established under the General Directorate. The studies of the Department that aim to improve the quality of care services are structured under the Quality Standards for Care Services and the studies for using them as an assessment scale are examined. Results: In order to ensure integrity for care services in Turkey, The Care Standards are structured under the Quality Standards of Hospital Services adopted by the Ministry of Health. When the Quality Standards were determined, both the national and international scale practices were examined and a method allowing harmonisation was chosen accordingly. First, the opinion of a group consisted of 20 professionals who were working in care services and the individuals who were getting these services were asked to inform their opinion regarding the created scale. The scale formed according to these opinions was later submitted to a group of 20 professionals consisted of academicians -‐ in order to get the opinions of these academicians who were responsible for training in the field of physiotherapy, medicine, nursing, social studies, psychology and nurse. The Quality Standards assess the institutional care services provided to the elderly and disabled persons under 4 main headings; Care Models, Corporate Governance, Care Services, Quality Indicators. Conclusion: In 2014, the training program of a group of professionals who will assess private and public institutions that provide care services according to Quality; these professionals were trained accordingly and the “assessor” training of the experienced professionals was terminated and the software that they would submit online assessments was completed. It is obvious that the Quality studies will provide important contribution to care sector. The increasing presence of private sector in care services also increases the necessity for the determination of quality scales. In the world where the obligation to adapt increasing free-‐market economy conditions dominate and the satisfaction analysis are sometimes inadequate (especially for mental disabilities, disorders or diseases); ensuring the elderly and disabled persons to receive good quality care services have become more important Being aware of this reality, the studies for the Quality Standards for Care Services continue in order to improve care standards in the sector and to provide good quality services for those in need, including the individuals who need cross-‐border care. References: Ozgobek R; Ankara, 2014 "bakım hizmetleri kalite standartları" ISBN: 978-‐6054628-‐47-‐6 2325 Does Caregivers Have Different Health Related Quality Of Life? Luis Antonio D. S. Diego* 1, Andrea Libório1, Marisa Santos1, Bernardo Tura1 1 Núcleo de Avaliação Tecnológica em Saúde -‐ NATS, Instituto Nacional de Cardiologia, Rio de Janeiro, Brazil Objectives: It is vital to understand how society values different attributes of health to supply policymakers with decision-‐ relevant data for the sake of health care planning and health technologies assessment process. Existing evidence suggests that caregiver burden may have a negative impact on Health Related Quality of Life (HRQOL). This study aims to investigate if caregivers value their own HRQOL differently than non-‐caregivers. Methods: A Multi-‐centric Cross-‐sectional study was conducted in three Brazilian urban centers aiming to derive Quality Adjusted Life Years (QALYs) based on estimates obtained from EQ-‐5D-‐3L valuation. A probabilistic sample of the Brazilian general population (n = 5785) stratified by age and gender valued 243 health states. Each respondent scored the EQ-‐5D-‐3L dimensions (Mobility, Self-‐care, Usual activities, Pain/discomfort, Anxiety/Depression) and valued seven health states using the Time Trade-‐Off (TTO). For the purpose of this study we defined “caregivers” as the subjects who reported have taken care of someone in the last 5 years. Results: Dimension Mobility Self-‐Care Usual Activities State No problem Have problem No problem Have problem No problem Have problem Caregivers % Non-‐Caregivers% 83,8 89,1 Dimension Pain/ Discomfort 16,2 10,9 85,3 89,1 14,7 10,9 Anxiety/ Depression 95,7 96,4 State No pain/ discomfort Pain/ discomfort Not anxious/ depressed anxious/ depressed 4,3 3,6 Caregivers % Non-‐Caregivers% 44,8 57,8 55,2 42,2 63 71,9 37 28,1 The gender distribution at caregivers group was 61% female/38,7% male, contrasting with the non-‐caregivers gender distribution of 46,7% female/53,3% male. The mean utility of the caregivers group was 0,87, meanwhile at the non-‐ caregivers was 0,9. The mean age at the caregivers was 39,8 (sd 12,7) and the non-‐caregivers the mean age was 37,5 (sd 13,2). Conclusion: Caregivers reported lower scores in all EQ-‐5D dimensions. Despite the utility valuation has been slightly lower on caregivers group, this association may be better explained by a higher prevalence of women in this group. 2330 A Modified Delphi Methodology To Gain Consensus On Assessing Frailty In Acute Care John T. Y. Soong1, Derek Bell1, Alan Poots* 1 1 Imperial College London, Chelsea & Westminster Hospital, NIHR CLAHRC Northwest London, London, United Kingdom Objectives: To gain expert consensus on the type of frailty indicators, method of assessment and characteristics of a successful frailty assessment tool for the acute medical care setting. To explore expert opinion as to the best method to measure and manage frailty in the acute medical care setting. Methods: A formal stakeholder analysis identified experts with interest in frailty locally, regionally and nationally. Panellists included academics, care managers, social care, consultant physicians, clinical psychologists, dieticians, general practitioners, nurses, pharmacists, physiotherapists, specialist charities and trainee specialist physicians. There were two rounds and the overall participation rates for Round 1 and Round 2 were 72.7% and 75.9% respectively. The electronic survey was developed and distributed using Survey Monkey™ software and was piloted over 2 iterative cycles to improve usability and validity. The survey software ensured consistent response rates by requiring responses for key questions. Resultant data tables were exported to Microsoft Excel™ for analysis. Descriptive statistics previously described by Holey et al. and Greatorex et al. were used to measure individual item consensus and stability. SPSS™ v21 was used to calculate Intra-‐Class Correlation Co-‐efficients for overall levels of agreement using two way random ANOVA with absolute agreement. Results: From a literature review, 31 identified frailty indicators were classified into 6 groups: Social Demographics, Phenotype model, High intensity service utilisation, Accumulated Deficits model (subgroup geriatric syndromes) and Bio-‐ Gerontological model. Participants ranked the usefulness of each of the items on a five point Likert Scale. The Accumulated Deficits and High intensity service utilisation models were perceived by panel members as most useful indicators of frailty in the acute care setting. The phenotype model was perceived as moderately useful and the bio-‐ gerontological model was perceived as least useful. Patient demographics were perceived to have moderate to low usefulness. There was a consistent pattern of percentage response rates between both rounds. Overall agreement improved from round 1 to round 2 (ICC 0.887 – 0.970) where ICC >0.8 denotes excellent agreement. Panellists responses for the question “what is the maximum number of frailty assessments that can be reliably measured in acute care” exhibited stable bipolarity across both rounds with a mode of 5 items and a smaller peak at 10 and >10 items. For the question of “when frailty assessment should be measured in acute care”, there was a similar bimodal distribution with a peak at “within 24 hours of arrival to hospital” and smaller one “At discharge”. For the questions of where frailty assessments should be done and how best to manage frailty in acute care, the distribution of responses was more evenly spread with modes of “Acute Medical Unit” and “Older Persons Liaison Services” respectively. Panellists were asked the open question “What characteristics are crucial for a successful frailty assessment tool in acute care?”. The responses were coded by frequency and presented as choices in Round 2. The final responses in order of frequency are “Clinically meaningful and relevant”, “Simple (easy to use)”, “Accessible by the multi-‐disciplinary team”, “Reproducible”, “Concise” and “Short”. Conclusion: The Accumulated Deficits and High intensity service utilisation models were as most useful indicators of frailty in the acute care setting. Panellists mostly felt a simple, clinically relevant tool should be used to screen for frailty on Acute Medical units within 24 hours. 2423 Implementing A Long Term Care Accreditation Program Maria del Mar Castellano Zurera1, José Antonio Carrasco Peralta1, Ramón De Burgos Pol* 1, Antonio Torres Olivera1 1 Agencia de Calidad Sanitaria de Andalucía, Sevilla, Spain Objectives: Firstly, to describe the key aspects needed to set up a social Accreditation Programme (AP) centered on Long Term Residential Care (LTRC). Secondly, to analyse the results obtained after the program implementation. Methods: The Andalusian Agency for Health Care Quality has launched the social care accreditation programme in 2013, based on: a consolidated own healthcare quality model in Spain and Portugal: • • • • • • • • • a classification of social services for the development of standards manuals , prioritising the long term residential services (LTRS) manual. Definition of blocks and quality criteria in which manuals are structured. Establishment of a Technical Advisory Committee (TAC). Description of the work schedule. Development a LTRS manual draft. Online application which supports the communication among the CTA members. Draft standards consensus. Adaptation of the online application that supports the health services accreditation processes. Assessment tools development (requirements, schedules, routes and evaluation guidelines) Once the AP was defined, 5 LTRS (3 residential care: 2 nursing homes and 1 adult disability care and 2 shelter homes: a rehabilitation unit care and a children's accommodation and support service) were selected to pilot the program in order to check the suitability of its standards and refine the methodology of assessment. Piloting process (PP) timeline and milestones planned: • • • • June: to conduct LTRS visits in order to present the accreditation program June-‐November: self-‐assessment services, development support tools and qualifications of external evaluators. November: evaluation visits. December: to prepare evaluation PP report and incorporate improvements to the draft standards. Results: Regarding the AP: • • • • • • • Structured in 5 dimensions, 11 criteria and 104 standards. CTA : 11 experts in quality and social services , which includes 5 face to face meetings. 2 different evaluation agendas according to the type of service (residence / home) to increase the efficiency of the evaluation phase. LTRS accreditation program published in ACSA website. In relation to the PP: Self-‐Assessment (mean): totally completed standards (74), identified by project improvements areas (IA) identified by project (23.4), IA implemented (5.2) and self-‐evaluators (6.2) . Some of the IA identified for LTRS were the following: generation of guidelines, protocols and records (28.2 %), periodic evaluations (19.6 %) and training activities (17%). Assessment: All the LTRS (5) that have experienced the AP must initiate IA to meet the compulsory standards that have not been met during the evaluation process and, therefore, to get accredited. The main improvements are related to: users’ rights, maintenance of facilities and / or equipment, accessibility to buildings, emergency plans, security and user safety. Overall satisfaction with the accreditation process (9.1) and their usefulness to identify improvements (9.33). Conclusion: It has proved feasible to develop an LTRS accreditation program accreditation based on the ACSA model and the evaluation methodology used for healthcare services. The defined standards show high sensitivity to detect different levels of quality of the services as well as an adequate specificity for identifying critical situations. High satisfaction with the accreditation process. IA identified for LTRS are mainly aimed at reducing the variability of professional practice and enhancing their professional training. 1083 Improving Weaning Rate Of Prolonged Mechanical Ventilation Chen Yen Liu* 1, Shu-‐Fen Wu1, Kuo-‐Chou Hsieh1, Chin-‐Pying Wu1 1 Respiratory Therapy, Landseed Hospital, Taoyuan County, Taiwan Objectives: Standardised protocol-‐driven ventilator weaning and Team Resource Management (TRM) were utilised in order to improve weaning rate of prolonged mechanical ventilation and to reduce the duration of mechanical ventilation. Methods: All patients with prolonged mechanical ventilation from July-‐Oct 2013 were included in this project. The methods include: 1. Using a difficult weaning checklist for case discussion on a weekly basis and the results would be discussed with the attending physician. 2. Initiation of pulmonary recondition therapy 3. Using TRM (situation monitoring) -‐ ward rounds, and reporting weaning plan and progress to all medical personnel and family members. 4. Discussion with professionals after literature review to establish new weaning protocol 5. Ensure that all patient hand over is conducted in an ISBAR manner to ensure daily readiness for weaning. 6. Ensure that tracheostomy education is delivered to determine if re-‐intubation or tracheostomy is required after weaning. Results: Weaning rate has been increased from 38.6% to 51.6% after the countermeasure has been implemented for 4 months. The duration of mechanical ventilation has been reduced by 6 days. The hospital stay has been reduced by 1.6 days. The cost per patient has been decreased by NT$14,532. Common consensus of medical personnel towards the weaning project has been increased by 14.4%. Family members’ satisfaction towards the medical team has increased by 0.6%. Conclusion: This project suggests that utilisation of standardised protocol-‐driven ventilator weaning and TRM for prolonged mechanical ventilation is able to increase the weaning rate, reduce the duration of mechanical ventilation, hospital stay, and the cost. This method can be employed in the future to ensure healthcare quality and proper utilisation of medical resources. 1087 Lost In Translation? The Implementation Of Lean In Hospitals As A Multi-‐level And Multi-‐faceted Process. A Mixed Method Study Of Local Pre-‐conditions For Improvement Hege Andersen* 1, 2, Kjell Arne Røvik2 1 CEO office, University Hospital of North Norway, 2Organisational studies, University of Tromsoe, Tromsoe, Norway Objectives: The specific aim of this study was to examine local lean preconditions in a Norwegian hospital and by that explore the travel of lean thinking. We argue that lean as an idea is translated and thus inevitably transformed when it travels into and within the hospital. Not only is lean translated; we also argue that the way it is translated can be decisive for outcomes. That is, for whether and how lean interventions works. Methods: In a recent international literature review we identified 23 factors which progress lean improvement in hospitals. Local preconditions were collected by semi-‐structured interviews of managers, consultants and hospital staff in 2012. A questionnaire (n=165) measured their relative importance. Results: The preconditions identified by the literature review were retrieved at the local hospital. The only exception was the reviews’ finding that external expert change agents, networks and sponsorships trigger change. This is not supported at the local hospital. All together approximately 90 different facilitating factors were reported by the interviewees. After an analytical process, categorising and grouping thematically connected factors, the list consisted of 21 additional preconditions, not retrieved from the literature review. The results from the questionnaire contribute to knowledge of which preconditions that may contribute the most to lean success. Table 1 present the 12 most important preconditions according to the respondents locally at the hospital. Table 2: The most important preconditions for change, questionnaire (n=165) Setting Management structure support Organisational structure 59% Vision Targets of urgency and direction, realistic, simple and practical solutions 48% Need for change Perceived need 36% Content Customer focus Include patient and staff improvement 58% Bottom up Improvement from work floor, voluntariness 49% Application Team work Multi-‐skilled and –disciplinary collaboration 61% Credibility No bragging, trustworthiness, no dismissals or cuts 34% Outcomes Few, palpable measures Concrete 66% Problem, not method focus Lean as a meeting place 48% Internal consultants Project management skills, mentors and network 34% Holistic approach Lean as a entire value system, every day improvement 43% Realism and patience Distinct mandate, demarcation, small projects, adjustments 45% * Balled: exclusively locally identified preconditions. Conclusion: The local preconditions were more practical, pragmatic, and sceptical than the reviewed ones. Further, local actors emphasised different preconditions according to the organisational level they belonged to. Lean were sold in, edited, partial copied and partial washed out, resulting in a local version of lean. These insights contribute to understanding why outcomes of lean vary among and inside hospitals. Awareness of the fact that translation makes a difference, increase the prospects of achieving desired outcomes in hospital quality improvements. 1100 The Characteristics And Risk Factors Of Unexpected Out-‐Of-‐Hospital Cardiac Arrest Within 72 Hours After Emergency Department Discharge Kuan-‐Han Wu* 1, Chao-‐Jui Li1, Yuan-‐Jhen Syue2, Chi-‐Wei Hung1 1 Emergency Medicine, 2anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan Objectives: Unscheduled revisits to Emergency Departments (EDs) within 72 h are a widely reviewed quality assurance tool; however, to our knowledge, patients developing unexpected Out-‐of-‐Hospital Cardiac Arrest (OHCA) within 72 h after ED discharge have never been studied. The objective of this study was to determine the characteristics and outcomes of this group of patients. Methods: We conducted a 10-‐year retrospective study in five EDs with > 500,000 annual visits from January 1, 2002 to December 31, 2011. Adult patients who developed non-‐traumatic OHCA within 72 h after being discharged from the ED were included. Descriptive statistical variables including demographics factors, vital signs, chief complaints, and laboratory tests were documented. Underlying diseases included in the Charlson Comorbidity Index (CCI) were also recorded. The scores were calculated as follows: one point each for myocardial infarction, congestive heart failure, peripheral vascular disease, dementia, cerebrovascular disease, chronic lung disease, connective tissue disease, ulcers, and chronic liver disease; two points each for hemiplegia, moderate or severe renal disease, diabetes mellitus, diabetes mellitus with complications, tumours, and leukaemia/lymphoma; three points each for moderate or severe liver disease; and six points each for malignant tumours, metastasis, or acquired immunodeficiency syndrome. To survey the risk factors of these patients, the control group in our study comprised the consecutive patient discharged after each study group patient. Logistic regression analysis was used to identify the independent risk factors for cardiac arrest. Results: The annual incidence of OHCA within 72 h of ED discharge was less than 2/100,000, which is much lower than the national OHCA incidence (73/100,000). Among the 162 included patients, majority were men (67.9%). The chief complaints of the first ED visit were mostly symptom-‐based, including dizziness or malaise (33.3%), followed by abdominal pain (13.6%), and dyspnoea (11.7%). The most common etiologies of cardiac arrest were of cardiac origin (48.8%) and due to respiratory problems (16%). Etiology of OHCA events had a causal relationship with the first ED visit in only 93 patients (57.4%). Considering the resuscitation outcomes, 123 patients (75.93%) had no return of spontaneous circulation and only 9 patients (5.55%) survived to discharge. The study group included more male patients, of older age, had lower body mass index (BMI), and longer ED length of stay (p<.001). The study group patients had higher triage acuity levels and CCI scores (4.5 ± 2.3 vs. 2.3 ± 2.1, p<.001), and underwent more radiological studies (64.6% vs. 41%, p < 0.001) and electrocardiography (31.7% vs. 16%, p=.003) than the control group patients. The study group patients also had poor laboratory outcomes, including lower haemoglobin, higher creatinine levels, and bandemia. Logistic regression analysis revealed that the male sex (odds ratio [OR]: 2.6, 95% confidence interval [CI]: 1.2–5.7), lower BMI (< 18.5 kg/m2, OR: 7, 95% CI: 2.0–24.3), and high CCI score (OR: 1.6, 95% CI: 1.3–2.1) were risk factors for OHCA occurrence within 72 h of ED discharge. Conclusion: OHCA within 72 h of ED discharge is a rare but crucial event due to its potential medico-‐legal consequences and patient safety concerns. Patients who developed unexpected OHCA within 72 h of ED discharge were likely to have multiple comorbidities, be in poor general health, and have a longer stay in the ED. The risk factors related to cardiac arrest within 72 h of ED discharge included age, male sex, low BMI, and high CCI. 1131 Implementing Successful Hand-‐Hygiene Program: Prospective Study Ali S. Al Qahtani* 1, Farouk M. Messahel2 1 Vice Dean for Academic Development and Quality, College of Medicine-‐King Khalid University, Abha, 2Director of Quality and Patient Safety, Armed Forces Hospital Southern Region, Khamis Mushait, Saudi Arabia Objectives: The "SAVE LIVES: Clean Your Hands" is a major component of "Clean Care is Safer Care" global campaign introduced by the World Health Organization (WHO) and is gaining momentum worldwide. In our efforts to reduce the spread of potentially life-‐threatening infections and their consequences, we decided to establish a Hand-‐Hygiene Program in our Intensive Care Unit (ICU). Methods: Signs demanding users to wash their hands when entering the unit, before and after examining patients and performing procedures were placed at several visible sites to users. The unit has enough sinks with soap, running hot water, and disposable paper tissues for drying the hands. Antiseptic gel dispensers were mounted at several locations. Hand Hygiene Knowledge Assessment Questionnaire was distributed among healthcare workers using the ICU, followed by a one-‐week single-‐blind observational survey to determine the extent of the practice between the users. In week two there was a series of lectures, demonstrations and training on all aspects related to hand-‐hygiene. The same Questionnaire was repeated in week three together with the hand-‐washing observations. Results: During the period of the study there were 77 health-‐care workers using the unit. The pass rates in answering the questionnaire amongst them were 52% in week-‐one and 91% in week three. The unit was visited by healthcare personnel 783 times during week one and 814 times in week three. Observations of practicing hand-‐washing in the two groups during the two periods were 59% and 98% respectively. Conclusion: Although hand hygiene is a simple act, there is lack of commitment by health-‐care workers. This study demonstrated that implementing a robust plan containing aspects of education, training and observation is proving successful. 1147 Evaluation Of The Quebec E-‐Health Record Medication Functions -‐ Potential Benefits And Barriers To Its Realisation According To Early Users Of The Technology Aude Motulsky* 1, Claude Sicotte2, Marie-‐Pierre Gagnon3, Robyn Tamblyn1 1 Clinical and Health Informatics Research group, McGill University, 2Administration de la santé, Institut de recherche en santé publique de l'Université de Montréal, Montréal, 3Faculté des sciences infirmières, Université Laval, Québec, Canada Objectives: The web based Quebec e-‐Health Record (QeHR) is being implemented in pilot regions of Quebec since 2011. The objective of this study was to evaluate the impact of the medication related functions of the web based QeHR used by primary care physicians and pharmacists in the pilot regions (Quebec City and Lanaudière). Methods: The data collection consisted of 80 interviews with physicians (12), managers (5), pharmacists (63), and pharmacy technicians (5), who were identified as the highest users of the QeHR (from utilisation data retrieved from the Régie de l’assurance maladie du Québec). The interviews were completed with think-‐aloud observation of specific tasks associated with the e-‐prescribing functions of the QeHR. We classified the perceived benefits per each step in the medication management process. Moreover, we identified barriers to the actualisation of the promised benefits of the QeHR, according to these early users of the technology. Results: Two medication-‐related functions were critical to QeHR-‐connected clinicians: the creation of a central medication history that is accessible to both physicians and pharmacists; and the electronic transmission of prescriptions. Overall, clinicians perceived that these functions had the potential to lead to an improved medication review, improved quality of prescriptions, and improved efficiency in their work. However, these potential benefits were impaired by the actual characteristics of the technology, leading to safety and efficiency concerns. Overall, integration of medication data in local systems of both the pharmacists and the physicians was incomplete. First, the medication history was generally not integrated in the local profile of the patient. Consequently, the clinician had to consult the medication history in a separate screen, and this data was not included in the computerised analysis of the profile for alerts. Second, the directives field was not integrated as structured data in most of the systems. Hence, the clinician had to manually “copy-‐paste” the directives into the appropriate field, while comparing with the previous prescription to avoid errors. Again, no computerised analysis was possible at this step: the clinician was not informed if he was locally entering directives that differed from the one on the electronic prescription. This poor integration represents a serious threat to the safety of patients that has to be addressed to attain clinical benefits of electronic transmission of medication data. Finally, the length of the validation process, the requirement for a printed prescription, and the current execution process in community pharmacies impaired the potential efficiency benefits for clinicians. Conclusion: In our study, most of the interviewed clinicians continued to work in the local mode, using the QeHR functions only in specific cases (e.g. new patient, suspected abuse) because of technological limitations. Overall, the potential benefits associated with the QeHR are highly impaired by an incomplete application, allowing only for partial data management, leading to a partial and unsystematic use of the technology. 1158 Implementation Of Venous Thromboembolism Prophylaxis Protocol In A Tertiary Care Hospital Sandeep Budhiraja* 1 1 Clinical Data Analytics and Internal Medicine, Max Healthcare, New-‐Delhi, India Objectives: To roll out a Venous Thromboembolism (VTE) prophylaxis protocol in all hospitals of Max Healthcare (with a total bed strength of 2000, in North India), so as to make all these hospitals VTE-‐free over 12 months period, starting January 2014. Methods: Max Healthcare, a leading private healthcare chain in North India, is fully EHR (Electronic Health Record) enabled hospitals using Visit A CPRS. The present utilisation of VTE prophylaxis was evaluated to be about 40% only. The Department of Clinical Data Analytics, created in 2013, has been involved in using EHR to improve patient outcomes. We decided to embark on a journey, to help clinicians improve the VTE prophylaxis rates to 100%. An e-‐alert was built into the CPRS, which would remind all physicians to do a simple risk assessment of all their patients for VTE and this was coupled to defined order sets, leading to execution of appropriate VTE prophylaxis. If in case, the e-‐alert is not resolved with 24 hours, an SMS goes to the primary physician, as a reminder. The second level is Nurses empowerment, wherein the nurses have been empowered to at least put sequential compression devices on all patients, where the physician has not resolved the alert, within 24 hours and they would also remind the physician. 3rd level is real time intervention, wherein a dedicated team would go around the hospital wards and ICUs to ensure real time implementation of VTE prophylaxis. In case of any contraindication to chemical thromboprophylaxis or any other reason for not prescribing heparin, the physician is mandated to mention the specific reason. The last level is ongoing audit by the EHR, which tells us how well we are progressing with the implementation of the protocol. This would identify areas/individuals with poor compliance, which will then be resolved by the senior CDA members. Before launching this protocol, extensive sessions for creating awareness among nurses and doctors, were undertaken from October-‐December 2013, in form of CMEs (Continuing Medical Education) and video conferring with outside Delhi hospitals. Results: We will have results coming in from March 2014 onwards and we expect to see a very positive outcome (results) by the time of the conference. The audit results will come automatically through the EHR on a real time basis. Conclusion: VTE prophylaxis is a very important patient safety protocol. Most of the hospitals have a poor compliance unless an organisation has a clearly defined protocol and a will to support the program. The Clinical Data Analytics department and the Electronic Health Records are very important tools, which the healthcare organisations should invest in, to have good patient outcomes and be able to benchmark the quality of care, to the best in the world. References: Health IT-‐enabled quality measurement: Perspectives, Pathways and Practical Guidance. Agency for Healthcare Research and Quality. 1176 To Improve Nurses And Caregivers Compliance To Modified Diet And Fluid Consistencies To 100% In Ward 73 Within Six Months Siti Khadijah Zainuddin* 1, Huiyan Lu1 1 Department of Internal Medicine, Singapore General Hospital, Singapore, Singapore Objectives: Patients with dysphagia were not receiving the recommended texture diet and fluid consistency ordered resulting in signs of dehydration and malnutrition. In extreme cases, they were reported to develop pneumonia. These rendered Doctors to order Speech Therapists (ST) review, which costs $74.25. Audit on compliance of caregivers and nurses to modified diet and fluid consistencies were conducted daily over 3 weeks, revealing 50%>75% compliance rate. Inaccessible recommendations; language barrier; inadequate teaching; inaccurate measurement; appalling taste; unable to obtain thickener after office-‐hours; Next-‐Of-‐Kin uninformed; unaware of implications; overlooked recommendations; time consuming were root causes recognized through cause and effect diagram. Through multi-‐voting followed by Pareto principle, inaccessible recommendation; language barrier and inadequate teaching were focused upon. Our team aims to ‘To improve nurses’ and caregivers’ compliance to modified diet and fluid consistencies to 100% in ward 73 within 6 months.’ Methods: Implementation was done through Serendipity and Delphi techniques. Tree diagram and Prioritisation matrix was used to identify three best solutions, which includes: ! A board hanged on the wall above the head of the bed for easy accessibility ! Coloured adhesive labels explaining diet modifications recommendations ! A flip chart was produced for education. All materials were available in 6 languages (with English subtitles) and when possible pictures were used. Results: Staff unassigned to the room is aware of patient’s dietary modifications. Less time is spent reiterating orders. Caregivers have better understanding due to various languages and images resulting in patients receiving 100% correct diet texture. Nurses are able to spend time for quality nursing care. Money is saved due to avoidance of unnecessary Speech Therapist review, investigations and prolonged hospital stay and treatment. Conclusion: The study has met the objective to improve nurses’ and caregivers’ compliance to modified fluid and diet consistencies. The importance of communication ensures that patient safety is not compromised at any time and improves the communication between all healthcare professionals thus improving patient outcomes. 1226 Development Of Treatment Protocol For Hypoglycaemia Adult Inpatients Daniella V. C. Krokoscz* 1, Luciana M. D. Freitas2, Janilene M. D. S. Pescuma2, Denise D. Lezzi2 1 Diretoria Técnica Hospitalar, 2Hospital Sirio Libanes, São Paulo, Brazil Objectives: Propose a standardisation of hypoglycaemia treatment. Methods: After several in-‐person meetings, a scientific committee of a large philanthropic hospital composed of endocrinologists, nurses and nutritionists developed a protocol for hypoglycaemia treatment -‐ based on the latest scientific evidence -‐ which was submitted to the approval of the organisation’s clinical staff. In partnership with the Information Technology team, we developed a process for the treatment of hypoglycaemia linked to the process of capillary glycaemia test. The use of PDA (Personal Digital Assistant) equipment and the capillary glycaemia test as the sixth vital sign were parts of the strategy adopted. Results: The project resulted in the adoption of a protocol for treatment of hypoglycaemia by the medical staff. This treatment considers the variables: level of consciousness, availability of venous access, preferred access for treatment via (intravenous or gastrointestinal tract) and the value of glycaemia for recommending the product to be used in the treatment, as shown in Table 1. Table 1. Product used for the treatment of hypoglycaemia (capillary glycaemia <70mg/dl), according to level of consciousness, fasting and availability of enteral or venous access. Altered level of consciousness Y N Y N N N Y= Yes N= No I= Independent Fast I Y I Y N N Enteral access I I I I N Y Venous access N N Y Y I I Product 1 ampoule intramuscular Glucagon 1 ampoule intramuscular Glucagon 40 ml of 50% intravenous glucose 40 ml of 50% intravenous glucose 15 to 20g Carbohydrate Oral 200 ml apple juice (juice box) The content was released in prints (manuals) and electronics (e-‐mail, post on institutional website) ways. The nursing staff and the physician’s on-‐duty were updated about scientific concepts of hypoglycaemia treatment and trained in the practical handling of the PDA tool to record glycaemia results and treatment as recommended. The protocol is in use in the General Intensive Care Unit (GICU) since September. Conclusion: A computerised tool was developed to record glycaemia results. The computerised tool conducts the treatment to be adopted according to the recommendations of the approved protocol. 1251 Appraisal And Major Revision Of No-‐Fault Based Compensation/Causal Investigation System For Cerebral Palsy Shigeru Ueda1, Shin Ushiro* 1, Hideaki Suzuki1 1 The Japan Obstetric Compensation System for Cerebral Palsy, Japan Council For Quality Health Care, Chiyoda-‐ku, Tokyo, Japan Objectives: The Japan obstetric compensation system for cerebral palsy was launched in 2009 in response to the shortage of obstetrician due to surging conflict on profound cerebral palsy cases. The system has undergone first major overhaul in terms of eligibility criteria in 2013-‐2014. The system growing in Japanese healthcare providing system is reviewed. Methods: Japan Council for Quality Health Care (JCQHC) has operated compensation/causal analysis and prevention system for profound cerebral palsy. The collection of insurance premium from childbirth facilities and the payment of compensation money to a guardian bearing a baby with profound cerebral palsy have been conducted in cooperation with indemnity insurance companies. Guardians with children suffering cerebral palsy are paid monetary compensation and provided a causal investigation report. The system was approved of expansion in terms of eligibility considering the effectiveness on easing conflict and quality and safety improvement in obstetric care. Revised system is to be implemented in 2014. Results: The Japan obstetric compensation system has achieved 99.8% participation of childbirth facilities. Eligible case is provided with monetary compensation such as 6 million yen (US$58,000) for lump-‐sum payment and 24 million yen (US$232,000) for 20-‐time annual instalment payment. Review committee to discuss eligibility of patient only confirms birth weight, gestational week and congenital or post-‐natal factor causing cerebral palsy. Liability of obstetric care is out of scope featuring the review process as “No-‐fault basis”. Expert groups have been intensively working to compile investigation reports. Three hundred and nineteen reports have been completed and delivered to both families and childbirth facilities so far. The production of report has proved to be favoured both by guardians and childbirth facilities. Despite the initial criticism that intensive causal analysis may ignite conflict between childbirth facilities and families, no significant rise in the number of liability insurance payment for cerebral palsy has been observed. In contrast, it has been observed that the decline of lawsuit cases in obstetric specialty is sharper than that of entire medical field. The system published a written material in 2013 carrying 5 important themes to improve quality of obstetric care such as care for umbilical prolapse and placental abruption, administration of uterine contracting agent, resuscitation of neonate in life-‐ threatening condition and appropriate recording on delivery process. The report is circulated among obstetricians or midwives on occasions such as annual meeting of scientific societies. With those improved care on the background, the nature of cerebral palsy born during 31-‐32 gestational weeks has grown similar to that of 33 weeks or later which are currently eligible gestational weeks. In early 2014, the expansion of the system in which cerebral palsy of 32-‐week gestational age is added to eligibility criteria was approved in the government committee and it is expected that the system will be more influential in the improvement of obstetric care in Japan. Conclusion: The Japan obstetric compensation system for cerebral palsy has been effective in easing conflict on cerebral palsy cases and improving quality of obstetric care. References: 1. The website of the Japanese Obstetric Compensation System for Cerebral Palsy (Available only in Japanese): http://www.sanka-‐hp.jcqhc.or.jp/index.html 2. Guide to The Japan Obstetric Compensation System for Cerebral Palsy (English leaflet) http://www.sanka-‐ hp.jcqhc.or.jp/pdf/bira_english_color201109.pdf 1268 Enhancing Quality And Patient Safety By Designing And Complementing Medication Management With A Clinical Decision Support System In An Academic Hospital Of Pakistan Abdul Latif Sheikh* 1, Syed Shamim Raza1 1 Department of Pharmacy Services, The Aga Khan University Hospital, Karachi, Pakistan Objectives: To prevent medication errors by determining effectiveness of Clinical Decision Support System (CDSS) interventions into existing Computerised Physician Order Entry (CPOE) system and its outcomes Methods: A thorough search was carried out to identify relevant studies with key words ‘CDSS and ‘CPOE’ related trials while observational studies were evaluated’ The study was designed to focus on pre and post implementation data of the in-‐ house designed clinical decision support system. During Phase 1, retrospective baseline data of preceding six months of dose related medication errors and pharmacist intervention of paediatric patients was extracted. During Phase 2, software for CDSS was prepared and integrated with the existing CPOE Results: The targets were to reduce approximately 25% dose related medication errors for patients admitted in the paediatric service after implementation of CDSS adjoined with our existing CPOE. The CDSS interventions became LIVE on August, 2013 with sixteen targeted medications which have increased substantially since implementation. The results have been encouraging compared with pre to post intervention dose related errors 65% (pre CDSS intervention) to 45% (post CDSS intervention) i.e. 20% low dose related errors. It is anticipated that the set target of 25% reduction would be easily achieved with passage of time and as the new medication are added. Conclusion: During the search and project implementation it was determined that very few studies have measured the impact of CPOE with CDSS on the rates of Adverse Drug Events and curtailing medication errors. Scarcity of data was obvious while searching data on randomised controlled trials. In country like Pakistan where health systems and patient safety is a major challenge due to structural fragmentation, resource scarcity, minimal or no regulatory control, above initiative of The Aga Khan University Hospital and support of international agencies will greatly benefit patient population of Pakistan. 1277 Sepsis Kills -‐ But Not In New South Wales, Australia Rosemary Sullivan* 1, Mary Fullick2, Lisa Coombs1, Paul Hunstead3 1 Sepsis Project Officer, 2Sepsis Program Lead, 3Paediatric Sepsis Project Officer, Clinical Excellence Commission, Sydney, Australia Objectives: Lack of or late recognition of patients with sepsis leads to high mortality rates and poor patient outcomes. The SEPSIS KILLS program aimed to improve the early recognition and key management actions of patients with sepsis and septic shock, and provide clinicians with tools to achieve this. Methods: A Clinical Excellence Commission Clinical Focus Report on the Recognition and Management of Sepsis1 showed significant deficits in the identification and management of sepsis. The SEPSIS KILLS Program was developed and implemented to improve the process of recognition and management of sepsis as well as provide an audit process to monitor progress. The Program was developed and implemented in Phases. Phase 1 focussed on recognition and management of patients in adult emergency departments with sepsis and progressed to paediatric patients in emergency departments. An online database has been developed and implemented as well as a toolkit of resources and online learning. Analysis of preliminary data has been linked with state-‐wide hospital data. Regular teleconferences and learning sessions are held. Expert clinical groups contributed to the development of pathways and antibiotic guidelines. Phase 2 is currently in development for whole of hospital implementation which we plan to align with the deteriorating patient program. Results: The message of – Sepsis is a medical emergency – is spreading across NSW. There has been strong uptake by clinicians in NSW emergency departments for the Program as: 180 of 188 hospital emergency departments have implemented the Adult Sepsis Pathway; and 145 of 190 hospital emergency departments have implemented the Paediatric Sepsis Pathway. 96 hospitals are entering adult data and 52 are entering paediatric data. The number of patients in the database up to December 2013 is 12800 or approximately 300-‐450 per month. All patients in emergency departments who meet the pathway or have a clinical suspicion of sepsis and have received intravenous antibiotics can be entered into the online database and there are no exclusion criteria. Time to administration of intravenous antibiotics in NSW has decreased from almost 4 hours to consistently less than 60 minutes from time of recognition. Time to administration of the second litre of resuscitation fluid has decreased from 4 hours to 90 minutes. Mortality has been stable, it is noted that a high percentage of patients with a raised lactate level are transferred to the wards from the emergency department rather than to an ICU area. The importance of measuring lactate levels and closely monitoring those patients has been highlighted as the mortality rate of those patients with a lactate level of greater than 4mmol/L is approximately 27% in our dataset. This has given us valuable insight into the management of sepsis. Conclusion: To date this program has been successful in improving both the early recognition and management of the septic patient. It has been widely adopted and has improved the processes for recognition and management. References: 1 Clinical Excellence Commission (2009) Clinical Focus Report From Review of Root Cause Analysis and/or Incident Information System (IIMS) Data -‐ Recognition and Management of Sepsis. 1293 Toolkit: Catalogue Of Infection Prevention Measures To Decrease Risk Associated With An Indwelling Urinary Catheter And Achieved Results Donna Armellino* 1, Catherine Galla2, Denise Mazzapica2, Kerri Scanlon3 1 Infection Prevention, North Shore -‐ LIJ Health System, Lake Success, 2Nursing Institute, North Shore -‐ LIJ Health System, New Hyde Park, New York, 110401, 3Nursing, North Shore University Hospital, Manhasset, New York, 11030, United States Objectives: Health care-‐associated infections such as Catheter-‐Associated Urinary Tract Infections (CAUTIs) cause patient harm; increased morbidity, mortality, hospital cost, and length of stay1. Our objective was to decrease CAUTIs among adult Intensive Care Unit (ICU) patients. Methods: In August 2013 the nursing and medical leadership of a large health system in the United States focused on improving CAUIs and started a CAUTI infection prevention initiative in 32 adult ICUs within eleven (11) acute care hospitals (5 tertiary and 6 community hospitals). A multifaceted intervention lead by appointed CAUTI champions from each facility, initiated an insertion checklist, a daily rounding tool, and conducted a once a week point prevalence evaluation. The three tools included elements of care outlined by the Centers for Disease Control and Prevention1 and were used as care guides to increase awareness and adherence to the insertion and maintenance bundle. Ongoing monthly meetings with the CAUTI champions identified barriers and challenges that were discussed with proposed solutions for implementation. The Plan-‐Do-‐Check-‐Act (PDSA) cycle was used to evaluate implemented strategies. We standardised indwelling urinary catheter that included a sealed juncture between the Foley and fluid collection bag and a securing device to limit the movement of the catheter after insertion. Health care provider education, development of supportive policies and procedures, reminder signs, and infection prevention rounds were implemented. CAUTIs were identified in patients within the adult ICUs, as well as adults patient care units using the National Healthcare Safety Network definition. Baseline data was collected from January 01, 2012 through August 31, 2013, and post-‐intervention data from September through November 2013. Analysis was performed to determine whether the intervention was associated with reduced CAUTIs. Results: Review of the completed insertion checklist, a daily rounding tool, and once a week point prevalence evaluation supported increase compliance with the outlined standard of care for an indwelling urinary catheter. We catalogued our procedures, interventions, supportive documents, and measurement tools within a CAUTI Toolkit for facility reference and dissemination within the healthcare community. The number of CAUTI events in 2013 dropped from an average per month of 41 in the pre-‐intervention period to 22 in the post-‐intervention period. There were 332 pre-‐intervention CAUTIs for 2.72 infections per 1,000 indwelling urinary catheter-‐days and 71 post-‐intervention CAUTIs for 1.79 infections per 1,000 indwelling urinary catheter-‐days. The decrease between the two time periods was 34. 4%. Conclusion: The data supported a significant decrease in CAUTI rates when infection prevention measures, supported by leadership, were integrated into routine care. Efforts are underway to standardise protocol across the health system and to continue to sustain the reduction in CAUTI. References: Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA, and Healthcare Infection Control Practices Advisory Committee Guideline for prevention of catheter-‐associated urinary tract infections 2009. Infect Control Hosp Epidemiol 2010;31:319-‐26. 1298 Tracking The Specimen Workflow By Using Barcode Specimen Tracking System To Improve The Safety Of Patient’s Specimens Hung-‐Tse Lin* 1, Yung-‐Ta Chang1, Shu-‐Yu Peng1, Hsiao-‐Chen Ning1 1 Department of Laboratory Medicine, LinKou Chang Gung Memorial Hospital, Tao-‐yuan, Taiwan Objectives: Tracking the specimen workflow is one of the important things in the department of clinical laboratory, especially with high daily volume of over 10000 specimens in Chang Gung Memorial Hospital. It can improve the turnaround time of specimens from blood collection to the laboratory. Besides, it also helps medical technologists find out shared specimens efficiently for the needs of repeat or additional testing. For these purposes, we use barcode specimen tracking system to promote the safety of patient’s specimens. Methods: Barcode system, which has been applied on the labelling specimen for many years in our hospital, is used for patient identification and for tracking the specimen workflow. In the ward or emergency room, before drawing blood from patients, the nurses use wireless scanner to scan the patient wristband ID and then print out V-‐notch barcodes for labelling tubes. At the same time, this process of patient identification records the nurse’s name and the time of blood collection in the Laboratory Information System (LIS). Since October 2009, we used the automatic tube barcode labelling system for improving the patient and specimen identification in the outpatient phlebotomy room. In addition, using V-‐ notch barcodes prevents relabeling caused by misaligned labelling. The statistics of poor labelling was calculated from January to July in 2011. Moreover, tracking the specimen workflow by using barcode system can make sure that the time of transportation is reasonable. It depends on the barcode specimen tracking system to monitor the specimen workflow. All specimens from the ward and emergency room, which are tracked when leaving the station and receiving in the core laboratory, are registered by scanning tube barcodes. Those from the outpatient phlebotomy room are transported to the core laboratory by the conveyor system and then sorted and registered by the automatic sorter. We compared the time of specimen transportation by labours with that by the conveyor system in 2010. Furthermore, all specimens are also tracked at every section of Total Laboratory Automation (TLA) system. After specimen analysis and test result verification, those specimens are transferred to the archival storage room and then localised by using LED light sample storage system. By using barcode specimen tracking system, all specimens are tracked through all steps in the process, including order entry, blood collection, transportation, registration, sorting, testing and storage. In this study, we investigated the cases of searching specimens from January to August in 2011. Results: By using V-‐notch barcodes, the amount of misaligned labelling decreased from 296 in January to 34 in July 2011. The time of specimen transportation from the outpatient phlebotomy room to the core laboratory by the conveyor system decreased from 37 to 6 minutes. By using barcode specimen tracking system, we reduced the cases of searching specimens from 9 cases per month to 1 case in 2011. In this way, the time we spent on looking for specimens decreased 6 hours per month. Conclusion: For tracking those specimens, all steps in the process from blood collection to specimen storage will be recorded precisely. Above all, using barcode system will be helpful for patient identification. Tracking the specimen workflow by barcode specimen tracking system really promotes the safety of patient’s specimens and improves the turnaround time. 1302 Exploring The Relationship Between Hospital Innovation Activities And Organisational Performance Kao-‐Piao Chung* 1, Yunyi Chen1, Tsung-‐Hsien Yu1 1 National Taiwan University, Taipei, Taiwan Objectives: In the past two decades, innovation has been widely discussed in practice and in the academic field and successfully applied in many industries. However, relations between hospital innovation and hospital performance were mostly examined through a single innovative activity or multiple combined activities in the past, which does not thoroughly obtain the whole picture of hospital innovation. Relevant issues still need further investigation. Methods: This study adopted the questionnaire survey along with secondary information. The subjects of the study were nationwide, including hospitals of regional level and above, and which offer at least 150 beds. Associations between hospitals’ technology innovation, management innovation and service innovation and their financial performance, quality management performance, operational performance and subjective organisational performance were analysed. The influences of hospital environment’s regional factors and perceived organisational support’s organisational factors on the aforementioned relations were also investigated. Results: A significant correlation was found between technology innovation and hospital performance. Technology innovation had positive influences on average profit per bed, diabetic patients’ serum creatinine examination execution rate, the rate of emergency department revisit within three days at the same hospital, the occupancy rate of hospital beds, outpatient market share, and performance measurement indicators such as subjective organisational performance. Perceived organisational support had positive correlations with average profit per bed, the total income growth rate, the occupancy rate of hospital beds, outpatient market share, inpatient market share, and subjective organisational performance. Regarding hospital environment’s regional factor, market competition level was found to have a significant correlation with average profit per bed, diabetic patients’ serum creatinine examination execution rate, the occupancy rate of hospital beds, outpatient market share, and inpatient market share. However, the regional factor did not have a moderate effect on the relationship between hospital innovation and hospital performance. Conclusion: Hospitals and clinics can be dedicated to developing innovation in medical technology so as to enhance their financial performance, operational performance, and quality management performance. 1303 Improving Daily Life Independency To Post-‐Rehabilitated Stroke Patients: Scoring By Barthel Index Yung-‐Yi Chen* 1, Tsung-‐Hsien Wang1, Allen-‐CL Hsu2 1 Departments of Rehabilitation Treatment, 2Physical Medicine and Rehabilitation, Landseed Hospital, Taoyuan County, Taiwan Objectives: Let stroke patients have better daily life quality and independent function is very important in home-‐living and social participation. We aim the improvement of Barthel index scores by giving interventions to rehabilitated stroke patients. In Taiwan, the most used tool to evaluate patient’s ADL function is Barthel Index. It includes different items for daily life functions, such as Feeding, Bathing, Grooming, Dressing, Transfer skill, Mobility, Walking Stairs, Bowels and Bladders function. We discuss the improving of daily life function of those stroked patients by Barthel index scores. More than that, we also discuss the independency of those patients. In preliminary data, 20 well consciousness post-‐stroke patients, which were received rehabilitation training, showed scores improving from 40.75 to 50.75 (P=0.06, no significant difference). Those patients were total depended of daily life. Methods: We analysed by Pareto Chart and revealed 4 issues to those patients: 1. Patients cannot take care himself with sound-‐side extremities, 2. Patients cannot understand the education sheets, 3. Patients cannot apply learned-‐skills from rehabilitation center to daily life, 4. Patients live in a protected environment and gain too much family help. So, we applied three different interventions. First, we reformed the education sheets. Second, we gave ADL-‐training specific class for stroke patients. Third, we also applied ADL training with video. Results: We included well consciousness 81 stroke patients from August to December 2012. Patients’ Barthel index score showed improvement from 40.75 to 64.25 (P<0.05) in reforming education sheet. Patients’ score also increased from 41.84 to 74.47 (P<0.05) in receiving ADL-‐training specific class. Patients’ score increased from 69.58 to 84.17 (P=0.001) in video training. Therefore, we also found that the male group, which is under 65 years old, had more improvement in Barthel index scores. Conclusion: In the past, therapists educated stroke patients for daily life, but they did not confirm the effect of educations. In this article, we gave those education interventions and improved patients’ daily life independency by a reliable index. It could be an important guideline for stroke patients in the future. 1304 Healthcare Quality Indicator Improvement Project Reduction Of Unplanned Re-‐Admission Rate Ying-‐Kuang Lin1, Huan-‐Sheng Chen1, Yu-‐Ju Huang2, Jui-‐Ling Hung* 3 1 Internal Medicine, 2Department of Quality Management, 3 Nursing Department, Landseed Hospital, Taoyuan County, Taiwan Objectives: Monitoring and improvement of healthcare quality indicators is the most direct and concrete way for the healthcare organisation to improve its healthcare quality. “Unplanned re-‐admission rate within 14 days after discharge due to the same or relative disease” is one of the most important healthcare quality indicators and the object of this indicator is to prevent patient discharge without proper preparation or prior to total recovery. In addition, the indicator also aims to maintain healthcare quality provided to patients to prevent unplanned re-‐admission. Methods: ! Comprehension of current condition: We were able to determine that unplanned re-‐admission rate within 14 days after discharge is a result of multiple factors through collection and analysis of healthcare quality indicator statistics, medical records review and discussion with the project team. The factors include: recurrence of disease, abnormal test results prior to previous discharge, iatrogenic complications, inadequate discharge preparation, patient lacks self-‐care ability, and etc. ! The project team established the countermeasures and executed them in a trial ward. The result of the execution was evaluated and promoted to the entire hospital in order to reduce unplanned re-‐admission rate. The countermeasures are as follow: 1. Drafting of discharge checklist for doctors, nurse practitioner and primary healthcare providers to complete prior to discharge. The content of the checklist includes: verify that test, examinations and symptoms have improved, healthcare education upon discharge, assistance for assistive devices and etc., in order to provide patients with a more thorough treatment and discharge preparation. 2. Integration of healthcare education resources and production of customised healthcare education sheets on the basis of healthcare issues such as healthcare guidance and utilisation of educational materials. 3. Reasons for re-‐admission were determined by the medical record review personnel and modifications were made to the categorisation of re-‐admission reasons stated in the healthcare system. Doctors are then able to elaborate the reason for re-‐admission to re-‐evaluate the individuals in order to provide appropriate healthcare services. The re-‐ admission reasons were then analysed statistically on a monthly basis and discussion would be conducted within the division in order to provide improvement schemes. 4. Conferences for unplanned re-‐admission within 14 days were conducted on a regular basis and participants include: doctors, nurse practitioners, case managers, nurses, nutritionists, physiotherapists, social workers, pharmacists, and etc. in order to improve communication within healthcare teams to provide better healthcare. Results: Average unplanned re-‐admission rate within 14 days after discharge due to the same or relative disease in 2012 was 2.33% and reduction was observed in 2013 after the implementation of the countermeasures. The average in October-‐ November 2013 was 1.6%. Conclusion: The cross-‐divisional project teams identified re-‐admission reasons and they proposed effective countermeasures in order to reduce the re-‐admission rate. These have served as an especially important reference for the healthcare teams and patients. Issues that could be resolved were identified via teamwork among the healthcare teams and continuous monitoring of high-‐risk patient population in order to reduce re-‐admission rate and wastage of medical resources and in turn improve patient care and healthcare quality. 1309 Adherence To The Surgical Safety Checklist: A Cross-‐Sectional Survey At The 97th Annual Meeting Of The Swiss Society Of Surgery Stéphane Cullati1, Delphine S. Courvoisier1, Marc-‐Joseph Licker1, Pierre Chopard* 1 1 University Hospitals Of Geneva, Geneva, Switzerland Objectives: To investigate the implementation of the Surgical Safety Checklist among Swiss surgeons and anaesthetists and to explore the self-‐reported compliance and attitudes toward the safety checklist. Methods: Cross-‐sectional survey, with self-‐administered questionnaire, at the 97th Annual Meeting of the Swiss Society of Surgery, Interlaken, 26th-‐28th of May, 2010, in combination with the Swiss Society of Anaesthesiology and Re-‐animation. Results: 433 questionnaires were distributed and 152 returned (participation rate 35%). 64.7% respondents acknowledged having a checklist in their hospital or their clinic. Median implementation year was 2009. More than 8 out of 10 respondents reported they team applied the Sign In and the Time Out very often or quasi systematically, whereas almost half of respondents acknowledged the Sign Out was applied never or rarely. Respondents agreed that the checklist improves safety and team communication, helps to develop a safety culture. However, they were mitigated about the opinion that the checklist facilitates teamwork and eliminates social hierarchy between caregivers. Conclusion: Use of the checklist among Swiss surgeons and anaesthetics participating to the 97th Annual Meeting of the Swiss Society of Surgery is spreading. Attitudes of respondents toward the checklist are generally good. 1344 Towards Resilience: The Evolution And Unveiling Of A New Improvement Science Model Andrew Johnson1, 2, Paul Lane3, Robyn Clay-‐Williams4, Jeffrey Braithwaite* 4 1 Executive Director Medical Services, Townsville Hospital and Health Service, 2School of Medicine and Dentistry, James Cook University, 3Intensive Care, Townsville Hospital and Health Service, Townsville, 4Australian Institute of Health Innovation, University of New South Wales, Kensington, Australia Objectives: Diligent application of current models of patient safety has consistently failed to yield expected improvements in healthcare around the world. We need new models that explore not only what has gone wrong in the provision of care, but importantly, why things go right most of the time. 1The way in which care is funded, managed and delivered is highly variable and highly complex. This can be better characterised as a Complex Adaptive System (CAS). 2CASs contain multiple self-‐organising agents whose iterating and interactive behaviours create outcomes that are emergent and not readily predictive. CASs are not amenable to traditional management approaches. This paper presents the Ten C’s Resilience Model -‐ a new, innovative model for conceptualising patient safety, which has emerged as a result of extensive collaborative efforts to improve patient care at a large Australian regional tertiary hospital over the last decade. Methods: Recognising how system adaptation affects how we manage and work within healthcare, the model evolved from a simple “linear” concept to one which incorporated system processes, including feedback loops, redundancies and discontinuities. Mentoring this development process required a fundamentally different way of thinking, operationalising new theoretical constructs, and applying innovative approaches to management and patient care. The model was developed in collaboration with health executives, front line clinicians and educators, and presents a simple description of the rules underlying complex behaviours required for safe and effective patient care. The model considers the complementary and interrelated roles of management, clinicians, patients and support staff. It challenges the orthodoxy of “patient-‐centred” care and suggests that it is not possible, nor desirable to characterise the patient as a “subject” of care. Rather, there needs to be a more robust understanding of the patient as a “participant” in care. In recognising healthcare as a CAS, we have also developed a “non-‐ linear” implementation pathway for the model, consistent with the way in which such systems are known to function. This represents a key contribution to improvement science and patient safety. Results: The model has been accepted throughout the Health Service at all levels, and has been discussed at state and national forums in its development. As the model continues to evolve, it incorporates and finds synergies with other improvement strategies, and reflects the need to understand “work as done” at the coalface, rather than “work as imagined” by executives. Conclusion: It is unusual for a patient safety model to emerge from within a health care setting – a more typical path is for safety processes and practices to be adopted from other industries, such as aviation. Implementation and further development are ongoing processes. Because the Ten C’s Resilience Model is emergent, adaptable and highly responsive to organisational needs, the specific characteristics of the model and how it is utilised vary across hospital departments and functional groups, thereby allowing clinicians a more flexible response and facilitating creative workplace solutions that are well-‐matched to the needs of clinicians and patients. References: 1. Hollnagel E, Braithwaite J, Wears R. Resilient health care. Surrey, UK: Ashgate Publishing Limited, 2013. 2. Braithwaite J, Clay-‐Williams R, Nugus P, Plumb J. Health care as a complex adaptive system. In: Hollnagel E, Braithwaite J, Wears R, editors. Resilient health care. Surrey, UK: Ashgate Publishing Limited, 2013. 1379 Quality Analysis Of Chinese Health Information Websites Siru Liu1, Jialin Liu* 2, Bianyin Song3 1 School of Mathematics, Sichuan University, 2Medical Informatics, West China Hospital Sichuan University , Chengdu, China, 3Medical Informatics, Peter L. Reichertz Institute for Medical Informatics, Braunschweig, Germany Objectives: The scope of China's internet users has reached 564 million (China Internet Network Information Center, January 2013). However, few patients access health websites for health information and medical education. Poor quality health websites are perhaps the reason. Our objective was to assess the quality of health websites based on HON (the Health On the Net) principles. Methods: A systematic review was carried out for the research dealing with the content of medical/health information websites. A literature search was conducted on electronic Chinese database (CNKI, Chinese National Knowledge Infrastructure ), to trace the research themes and methodologies of Chinese language research papers published from January 2000 to December 2012.Our inclusion criteria were the description of health or medical information websites(Chinese language). The health information websites got from search engines (Baidu and Google). Case studies were conducted on Alexa (Alexa the information company). Results: Searching the online database resulted in 120 articles. Eventually, a total of 26 articles met the inclusion criteria and were assessed. These studies showed major problem in Chinese health information websites. Searching in Google and Baidu resulted in 21,000,000 and 6,450,000 Chinese health web pages. We randomly chose 50 Chinese health websites to evaluate. We assessed top 10 Chinese health websites rated by Alexa (July 2013). According to HON code, all the health information websites were evaluated based on HON principles. These research revealed that none of Chinese health websites are accredited by HON. All the websites were considered incomplete, overly commercial and out of data. Conclusion: Seeking reliable and valid health information on the Internet can be very difficult in China because there is a lack of reliability of health information websites. The health information websites cannot meet the needs of the broad masses of the health knowledge and information. It is very important to establish a new model of Chinese health information websites. Disclosure of Interest: S. Liu Grant / Research support from: Sichuan University Innovation Plan (Grant Number: 2013022), J. Liu Grant / Research support from: National Natural Science Foundation of China (Grant Number: 71273182/G0308), Chengdu Science & Technology Bureau Innovation (Grant Number 13RKYB087ZF-‐041) , B. Song: None Declared 1453 Staff Experiences Of Implementation Of Standardised Handover Improvement Tools In The Post Anaesthetic Care Unit Kimberley E. Coleman* 1 1 Epworth/Deakin Centre for Clinical Nursing Research, Richmond, Australia Objectives: The purpose of this study was to explore clinician experiences of adopting quality improvement tools to standardise inter-‐professional (anaesthetist-‐to-‐nurse) handover communication when patients arrive into the Post Anaesthetic Care Unit (PACU). Methods: This study was part of a larger study to test implementation of handover improvement tools in PACUs across two large private hospital sites. A modified Relational Co-‐ordination (RC) survey1 was given to anaesthetists and PACU nurses to assess dimensions of relationships and communication between PACU disciplines. The context of the PACU environment was further explored using pre and post-‐implementation semi-‐structured focus group interviews with PACU nurses. Mean statistical analysis was conducted to calculate RC scores from the survey. Quantitative data was analyses using the PARIHS2 (context, evidence and facilitation) framework as a deductive framework analysis tool. Results: PACU nurses and anaesthetists both scored their relationships and communication with other PACU nurses highest of all PACU disciplines; PACU nurses in particular reported high RC scores regarding other PACU nurses (Site 1=3.74; Site 2=4.57). However, PACU nurses reported sub-‐optimal scores regarding anaesthetists (Site 1= 3.46; Site 2= 4.06 out of a possible 5) that were further reinforced by focus group findings: that PACU nurses felt too intimidated by anaesthetists’ “moods” (Site 1 FG2) or possible punitive actions making their “working relationship strained” (Site 2 FG 2) to ask questions during handover. Furthermore, PACU nurses at Site 2 identified feeling unsupported by management and lacking “authority” (Site 2 FG 2) in the OR as factors that hindered their willingness to challenge these behaviours and utilise the handover improvement tools. In comparison, visible support from leadership at Site 1 was described as encouraging nurses to be “assertive” (Site 1 FG 2) and take charge of their patient’s care. Conclusion: PACU nurses perceived the handover tools were useful and helped them identify gaps in handover practice; however, PACU nurses described difficult relationships and disruptive behaviours of anaesthetists as hindering communication effectiveness and discouraging their adoption of the tools. The necessity for strong leadership and organisational support to encourage change also emerged. The use of mixed method data provided in depth insight into the complex issues affecting quality improvement of PACU handover, providing direction for future research. References: 1. Gittell, JH, Fairfield, KM, Bierbaum, B, Head, W, Jackson, R, Kelly, M, Laskin, R, Lipson, S, Siliski, J, Thornhill, T & Zuckerman, J 2000, 'Impact of Relational Coordination on Quality of Care, Postoperative Pain and Functioning and Length of Stay: A Nine-‐Hospital Study of Surgical Patients', Medical Care, vol. 38, no. 8, pp. 807-‐19. 2. Dawes, M, Davies, P, Gray, A, Mant, J, Seers, K & Snowball, R 2005, Evidence Based Practice. A Primer for Health Professionals, 2nd edn, Elsevier Churchill Livingston, Edinburgh. 1497 The Use Of The Hospital Survey Of Patient Safety Culture In Europe Antje Hammer* 1, Tanja Manser2 1 Institute for Medical Sociology, Health Services Research and Rehabilitation Science (IMVR), University of Cologne, Cologne, Germany, 2Department of Psychology, University of Fribourg, Fribourg, Switzerland Objectives: Over the past two decades, measuring safety culture in health care has gained increased attention in international healthcare research. A large number of surveys have been published regarding safety culture in healthcare settings. One of these measurements is the Hospital Survey on Patient Safety Culture (HSPSC) -‐ designed to assess front line staff perceptions of patient safety culture in hospitals. The survey has been translated and adapted for use in European countries. This study aims to provide an overview of the use of HSPSC in hospitals throughout Europe and on the published evidence regarding its psychometric properties. Methods: We combined a web-‐based literature search on Medline and Web of Science along with an informal survey among individuals who had been in contact with the developers of the HSPSC regarding its potential use in Europe. Publications were reviewed focusing on the instrument development (translation/adaptation process), the data collection process and the psychometric evaluation within the countries. Results: In our initial literature search, we found 26 publications on the use of the HSPSC in European settings. By contacting single researchers, we received information about additional usages for the HSPSC. Overall, we identified 44 different studies from 20 European countries that have used the survey. In five studies, the origin HSPSC has been adapted for use in ambulant care settings. In another 20 studies, the adapted version of the questionnaire was not (or only to a limited extent) analysed for psychometric properties or the results were not available in English. In five studies, a psychometric evaluation has been conducted but the results were not published in time. Finally, we identified 14 out of 44 studies which have analysed psychometric properties of the translated and adapted survey. Exploratory Factor Analysis (EFA) had been conducted in two studies and Confirmatory Factor Analysis (CFA) in the case of another two studies. In ten studies, both methods had been used. Eleven studies tested the construct validity and internal consistency was reported in all 14 studies. Conclusion: The available evidence from studies conducted in Europe suggests that the HSPSC instruments developed from the original US version have to be adapted carefully to other national and/or healthcare contexts regarding terminology as well as including more systems related issues. Moreover, the procedure for psychometric testing varied between the different studies. According to established standards, psychometric testing of safety climate measures are necessary. However, this overview will support practitioners and researchers planning to use the HSPSC in their country. We discuss our results in light of the strengths and limitations, and point out areas for future research. 1521 Risk And Clinical Management Protocols: An Interface In Quality Improvement And Patient Safety Andreza P. S. Hamada1, Gisely M. Schrot1, Daniella B. Romano* 1, Fernando Colombari2 1 Desenvolvimento Institucional, 2Unidade de Terapia Intensiva, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil Objectives: Investigate all cases of deep vein thrombosis or pulmonary embolism in the hospital and analyse them as to adherence to clinical protocol of preventable VTE. Methods: Experience report of a tertiary hospital in implementing a process interface between risk management, the use of clinical protocol of preventable VTE and the physician relationship to improve and consolidate the institutional culture of quality and safety. Results: Fragmentation of the care process and the communication barriers between different professionals within a health care organisation is an important theme related to patient safety. Currently, risk management is a way of mapping and charting possibilities of improvement processes. Unexpected and undesirable events that cause harm to patients can be prevented, minimised and treated after risk management intervention. Despite significant advances in prevention and treatment of Venous Thrombo-‐Embolism (VTE), pulmonary embolism remain the most common preventable cause of hospital death. Then it is important to develop an institutional protocol to prevent VTE. But only the clinical protocol is insufficient to ensure adherence to best medical practice. For optimisation of clinical VTE prevention protocol, the interface between risk management and physician relationship should be strengthened. When the diagnosis of VTE is identified and reported as an adverse event to the management risk for analysis and investigation of possible non-‐compliance with institutional protocol and can thus become an adverse event. The process begins by performing the notification of patients diagnosed with deep vein thrombosis or pulmonary embolism at the hospital admission or during it. This notification is sent to the risk management that directs the same team of clinical protocols for analysis of the notification and the identification of possible lack of adherence to protocol. If so, this notification is treated as an adverse event and jointly analysed with the physician relationship area that thus, compose an item for the performance evaluation and feedback to clinical staff. If not, it is evaluated by the risk management relevance of the event to the patient's comorbidities and it is not considered an adverse event. This process interface assists in the review of the clinical protocol and in the mapping of the improvement actions that must be performed, using evidence-‐based medicine. Conclusion: The management processes by integrating areas search the patient’s safety by reducing unsafe acts in the health institution as well as the use of the best practices that seek the improvement of the final results. The result of the actions of prevention together with effective costs control involve, from reducing hospitalisation rate to the total hospitalisation costs, besides reducing the re-‐admissions, ensuring quality and safety of care provided to patients. 1527 Hospital Staffing And Hospital Acquired Conditions In Colorectal Surgery Tina Hernandez-‐Boussard* 1, Doug Morrison2, Kathryn McDonald3, Kim Rhoads2 1 Surgery & Biomedical Informatics, 2Surgery, 3Medicine, Stanford University, Stanford, United States Objectives: An essential element of the public health system is quality assurance and the close monitoring of patient outcomes and safety. Many standardised and endorsed quality metrics focus on patient outcomes and safety. Patient Safety Indicators (PSIs) were developed by the Agency for Healthcare Research and Quality to assist in monitoring potentially preventable events for patients treated in hospitals. Some indicators are thought to be related to physician practice patterns, but others are thought to be nursing sensitive. In previous studies, select hospital outcomes have been associated with staffing. We sought to investigate the relationship between PSI and nurse-‐to-‐patient ratios and following colorectal surgery. Methods: Retrospective analysis of national inpatient administrative data of all colorectal surgeries between 2008-‐2010. Data were linked to hospital survey data to obtain detailed information about hospital characteristics, including staffing, structure, and services. Patients were stratified by underlying disease based on ICD-‐9-‐CM codes. We examined PSIs and their association with the nurse-‐to-‐patient ratio using logistic regression. We adjusted for age, race, payer, co-‐ morbidities, hospital volume, and nurse-‐to-‐patient ratio. The association between nurse-‐to-‐patient ratio and each PSI was tested using a t-‐test for Pearson’s correlation. Results: We identified 693,766 colorectal surgeries; 47.6% for cancer, 10.4% for benign polyp, 29.3% for diverticular disease; 7.1% for Inflammatory Bowel Disease (IBD), and 5.6% for ischemic colitis. Within the colorectal group, ischemic colitis had significantly higher risk-‐adjusted rates for all PSIs (p<.05) followed by inflammatory bowel disease. Patients with cancer and benign polyps had overall lower risk-‐adjusted rates compared to all other colorectal surgical patients. We found no correlation between nurse-‐sensitive PSIs and nurse to patient ratios for all colorectal patients and for PSIs within individual diagnostic groups. The logistic regression models identified that nurse-‐sensitive PSI ‘failure to rescue’ was more strongly associated with the underlying diagnosis than nurse-‐to-‐patient ratio, even after controlling for patient demographics (p<.0001). Conclusion: In this study we found rates of PSI were correlated with the underlying disease. For nurse-‐sensitive PSIs, we found no correlation between PSI risk-‐adjusted rates and nurse-‐to-‐patient ratio. In fact, we found that nursing sensitive PSI rates were more closely correlated with the underlying disease for surgery. These results are in contrast to many current studies that have found a strong correlation for failure to rescue after surgical procedures. This evidence provides guidance for policymakers and hospital administrators about the allocation of nursing care: simply increasing nurse-‐to-‐ patient ratio may not be significantly correlated with improved outcomes for all patients. Other approaches, such as strategic allocation of nursing care based on disease severity, need to be further explored. 1530 Iatrogenic Prescription In Oncology: Application Of The Oncology Trigger Tool Guillaume Hebert* 1, 2, Florence Netzer1, François Lemare1, 2, Etienne Minvielle2 1 Clinical Pharmacy Department, Institut Gustave Roussy, Paris, 2Research Unit in Management of Healthcare Organisations, EHESP, Rennes, France Objectives: Oncology is an area in which drug-‐related iatrogenic effects are of utmost importance because chemotherapies are toxic in themselves. In order to prevent induced injuries, a risk assessment must be developed. There are currently existing practical methods that are able to, both identify Adverse Drug Events (ADEs) and measure the harm caused to the patient, but none of them are specific to oncology. This was one of the main concerns and a top priority at the Gustave Roussy Cancer Center in Villejuif (France). In 2012, the U.S. Agency for Health Research and Quality (AHRQ) recommended the use of the Global Trigger Tool method (GTT) developed by the Institute of Health Improvement (IHI) to identify ADEs. The aim of this study is to evaluate the risk associated with drug-‐related care for cancer patients at Gustave Roussy with an oncology-‐focused trigger tool method. Methods: The study was conducted from 2012-‐2013 and targeted patients treated at Gustave Roussy in 2011. We randomly selected 288 medical records corresponding to patients who had stayed at the center longer than 48 hours. According to the IHI’s methodology, a focused oncology trigger tool, which was developed and validated in the cancer centre, was used. Twenty-‐two "triggers" (keyword or threshold value), specific to cancer patients, have been developed. A flow-‐ chart for each one of the triggers was built, which helped to confirm or refute the association between the trigger and the onset of ADEs. The severity of the induced damage was evaluated on a 1 to 5 scale using the NCI CTCAE scale. Results: Study findings indicated an average length of stay of 9.2 days. On the first day, the average number of drugs per patient was 8.1 drugs. Among the 288 charts, 824 triggers were detected, accounting for 122 unique ADEs. There were 42.4 ADEs per 100 admissions and 46.0 ADEs per 1000 hospital days. The analysis showed that the most frequent ADEs were also the most serious. In conclusion, we found that "iatrogenic hyperglycaemia" (n = 18 including 10 graded 3 and above) and "unplanned readmission within 30 days, related to drug" (n = 17 including 14 graded 3 and above) was ranked the highest. The subpopulation analysis indicated that the standardised ADE rate was greater for patients over 65 years old (66.7 ADEs per 100 admissions). Conclusion: Our method, which was based on a targeted approach allowed to assess drug-‐related iatrogenic effects with similar or greater detection rates than those reported by other studies. One application of this method is to develop patient safety indicators to measure quality improvement. 1533 A Population Based Study Of The Secular Trends Of Cardiopulmonary Arrest And Mortality And Their Association With Rapid Response System Expansion Jack Chen1, Lixin Ou* 1, Ken Hillman1, Arthas Flabouris2 1 Simpson Centre for Health Services Research, Faculty of Medicine, the University of New South Wales, Sydney, 2 Internsive Care Unit, Royal Adelaide Hospital & University of Adelaide, Adelaide, Australia Objectives: To understand the changes in the population incidence of In-‐Hospital Cardiopulmonary Arrest (IHCA) and mortality associated with the increasing introduction of rapid response systems Methods: For the period 2002-‐2009, we compared a teaching hospital with a mature (Rapid Response System) RRS, with three similar teaching hospitals without a RRS. Two non-‐RRS hospitals began implementing the system in 2009 and a third in January 2010. We compared the rates of in-‐hospital cardiopulmonary arrest (IHCA), IHCA-‐related mortality, overall hospital mortality and 1-‐year post discharge mortality after IHCA between the RRS hospital and the non-‐RRS hospitals based on three separate analyses: 1) pooled analysis during 2002-‐2008; 2) before-‐after difference between 2008 and 2009; 3) after implementation in 2009. Results: During the 2002-‐2008 period, the mature RRS hospital had a greater than 50% lower IHCA rate, a 40% lower IHCA-‐ related mortality, and 6% lower overall hospital mortality. Compared to 2008, in their first year of RRS (2009) two hospitals achieved a 22% reduction in IHCA rate, a 22% reduction in IHCA-‐related mortality and an 11% reduction in overall hospital mortality. During the same time, the mature RRS hospital showed no significant change in those outcomes but, in 2009, it still achieved a crude 20% lower IHCA rate, and a 14% lower overall hospital mortality rate. There was no significant difference in 1-‐year post-‐discharge mortality for survivors of IHCA over the study period. Conclusion: Implementation of a RRS was associated with a significant reduction in IHCA, IHCA-‐related mortality and overall hospital mortality. 1547 Decrease The Failure Rate Of Pap Smear Test For Cervical Cancer Screening Hui-‐Ju Lin* 1, Hui-‐Chun Lo1, Shu-‐Chuan Yu1, Kuan Hui Lee1 1 Yonghe Cardinal Tien Hospital, New Taipei City, Taiwan Objectives: The pre-‐malignancy status of cervical cancer can be detected effectively by Pap smear test, which quality monitoring was important. We aim to lower the failure rate of Pap smear test by standardising the sampling procedures. Methods: There were 1083 subjects enrolled in the gynaecologic clinic of a local community hospital at New Taipei city from June to August, 2013. Before intervention, there were eighty failed samples (7.83 percent), which mainly due to improper sample fixation, improper timing and sampling technique. In order to lower the failure rate, we provided standardised procedures between September and October as follows: ! First, we change fixation solution with 95 percent alcohol every day to avoid contamination of samples. ! Second, the sample was marked with exact sampling time after fixed in the solution for twenty minutes. ! Third, educate the subjects with hand-‐out to make sure the proper timing for sampling. Finally, continuously check the correctness of procedures with doctors during monthly meeting. Results: After intervention, there were only 45 failed samples noted among 1465 subjects (3.2 percent) between September and December, 2013. In other words, the failure rate was decreased to 5.9 percent in October and 1.9 in December. Thus, the objective had been achieved. Conclusion: The failure rate of Pap smear test was significantly decreased after intervention, which save the medical costs and manpower, lower sickness dissatisfaction and enhance the patient-‐physician communication and quality of medical service. 1552 Decrease The Incidental Re-‐insertion Rate Of Nasogastric Tube In Homecare Patients Ya-‐Wen Lee* 1, Po-‐Yi Chin1, Ya-‐Wen Yang1, Kuan Hui Lee1 1 Yonghe Cardinal Tien Hospital, New Taipei City, Taiwan Objectives: To decrease more than 2.4 percent of the incidental reinsertion rate of NasoGastric (NG) tube in homecare patients Methods: We analysed 671 subjects in the homecare center of a local community hospital at New Taipei city from January to April, 2013. Before intervention, forty-‐four patients (6.6 percent) encountered dislodgement, which mainly due to self-‐ removal of NG tube (63.6 percent) and fixation tape loosen (22.1 percent). In order to lower the reinsertion rate, there were a number of strategies intervened as follows: ! First, we provided standard procedures for protective restrain and NG tube fixation, with patient education hand-‐ out. ! Second, homecare providers and nurses were educated to strengthen the perception and technique of protective restrain and NG tube fixation. Finally, evaluate the correctness of restrain and fixation procedures continuously during monthly visit. Results: After intervention, there were only seven cases with NG tube dislodgement noted among 336 homecare subjects between July and August, 2013. In other words, the reinsertion rate was decreased to 2.1 percent and the objective has been achieved. Conclusion: For long-‐term homecare patients with swallowing difficulty or totally incapable of swallowing, NG tube feeding were safe and convenient methods to maintain nutrition. When incidental NG tube dislodgement had occurred, the patients would suffered from pain and uncomfortable, and the ability of food and water intake would be diminished, followed by the increased risk for nutrition imbalance, aspiration pneumonia and the larger loading of the family and homecare providers. Fortunately, the NG tube incidental reinsertion rate was decreased after our procedures, and the harm and uncomfortableness to the patients were reduced. Furthermore, we eased the anxiety of the family, and saved the costs and enhanced the quality of homecare service. 1578 Discrepancies During Time-‐Out – An Analysis Of Over 130.000 Surgical Checklists Daniel Berning* 1, Daniela Renner2, Christian Vorderbrügge1, Christian Thomeczek2 1 Institute for Patient Safety (IFPS), University of Bonn, Bonn, 2German Agency for Quality in Medicine (AQuMed), Berlin, Germany Objectives: Holding all other activities to conduct a Team Time-‐Out (TTO) before the beginning of each surgical procedure is considered to be a simple means to increase patient safety. Since 2010 sixteen German hospitals have implemented the Standard Operating Protocol (SOP) for Correct Site Surgery (CSS) as a part of the WHO initiative “Action on Patient Safety: High 5s”. The last crucial step of this SOP is a TTO. An important tool to support clinical staff and to document processes is the High 5s surgical checklist. In contrast to other checklists, this checklist includes check boxes for noted discrepancies during TTO. The objective of this study is to analyse the frequency and type of discrepancies documented on the checklists during TTO. Methods: High 5s surgical checklists from all participating hospitals in Germany (n=16) from October 2010 to December 2013 were reviewed for the following TTO verification items: correct patient identity, correct procedure, correct site marking, correct patient position, correct images and correct implants / special instruments. Review of checklists was done electronically. The number of documented discrepancies and missing values for each item was calculated. Results: 136,819 checklists from 15 hospitals were analysed. One hospital was excluded from the analysis because their checklist did not include all 6 mandatory TTO items. Among 820,914 mandatory checklist items, 131,515 (16.02%) of them were not filled in (missing items). 3,160 discrepancies were registered in total. On 2,170 checklists (1.59%), at least one discrepancy was documented. Documented discrepancies for single items were as follows: correct site marking 1,243 (39.34%), correct images 785 (24.84%), correct implants / special instruments 553 (17.50%), correct procedure 252 (7.97%), correct patient positioning 171 (5.41%) and patient identity 156 (4.94%). Conclusion: Team time-‐out leads to detection of discrepancies with regard to correct site surgery. In our group of German High 5s hospitals, most discrepancies detected during TTO, were discrepancies concerning the correct mark of the surgical site followed by discrepancies concerning images (e.g. X-‐rays). The true number of discrepancies detected during TTO might be higher, since our results are compromised by an inadequate adherence to complete documentation. Factors contributing to the occurrence of discrepancies need to be examined in further studies. 1609 How Time Consuming Is The Surgical Team-‐Time-‐Out? Daniela Renner* 1, Daniel Berning2, Christina Gunkel1, Christian Thomeczek1 1 German Agency for Quality in Medicine (AQuMed), Berlin, 2Institute for Patient Safety (IFPS), University of Bonn by order of the German Coalition for Patient Safety (APS), Bonn, Germany Objectives: Surgical safety checklists are effective tools for improving patient safety. An essential part of surgical safety checklists is the “Team Time Out” (TTO). This formal pause without any other activities, immediately before the first incision, is used for enhancing the communication among all surgical team members. Nevertheless, the TTO requires an additional time and effort. This can be considered as waste of time and disrupting of work flow and therefore, is a barrier for implementing the TTO process. Since 2010 16 German hospitals have implemented the standard operating protocol (SOP) for “Correct Site Surgery” (CSS) within the WHO initiative “Action on Patient Safety: High 5s”. One key step of the SOP is the TTO which is a part of the High 5s surgical safety checklist. The objective of this study is to analyse the duration of the surgical TTO. Methods: The German hospitals which have participated in the project at the time of September 2013 (n=10) were able to accomplish the TTO measurement. The TTO of the High 5s surgical safety checklist varied between hospitals, but at least the following mandatory verification items were part of each TTO: patient identity, correct procedure, correct site, correct patient position, correct images, and correct implants/special instruments. During a defined period of 48 hours, the duration of performing and documenting the TTO should have been measured for every surgical procedure including emergency cases. One freely chosen member of the surgical team was responsible for the time measurement. The hospitals collected their data paper-‐based. Afterwards, the data was statistically analysed by the Institute for Patient Safety. Results: 7 of the 10 hospitals with different levels of care contributed to the measurement of the TTO. The length of the TTO was measured for 204 of 242 recorded interventions. The TTO lasted 57 seconds on average 50% of the TTO time took up to 45 seconds (median), 75% of the TTO time lasted up to 68 seconds (upper quartile). In 96% of all measured cases the TTO could be accomplished within 2 minutes. 8 of 204 measurements were performed in emergency procedures. The average duration of the TTO for emergency procedures was 59 seconds, the median was 49 seconds and the upper quartile was 65 seconds. Conclusion: The additional needed time for the surgical TTO is minimal and therefore, the perceived “waste” of time should not form a barrier for implementing this effective patient safety tool. In the context of emergency interventions a TTO can also be carried out in a very short time. Further investigation is needed, whether the TTO allows to reduce the whole surgery time as well as to increase the efficiency of surgeries by enabling an early detection and prevention of complications. 1630 The Implementation Of Team Resource Management (TRM) To Achieve Complete Post-‐Operative Handover Of Cardiac Surgery Patients To The Intensive Care Unit (ICU) Yi-‐Chun Chen* 1, Chia-‐Lin Lee1, Jiun-‐Yi Li2, Jen-‐Kun Cheng1 1 Department of Anaesthesiology, 2Cardiovascular Surgery, Mackay Memorial Hospital, Taipei, Taiwan Objectives: Patients who require direct post-‐operative transfer to the ICU are often those with severe systemic diseases that are at a higher risk for further complications. As a result, more post-‐operative invasive monitoring and medications are used to support organ function in order to maintain patients’ hemodynamic stability after the operation. Clinical handover or handoff between caretakers or multi-‐disciplinary teams is a transfer process of professional responsibility in all aspects of care for a patient. Effective handover is essential for ensuring patient safety and the continuity of treatment process during hospitalisation. If the post-‐operative handover is incomplete or incorrect, it can be full of many technical errors with miscommunication that can greatly affect the quality of care and patient safety. Therefore, this article discusses the post-‐operative handover process for cardiac surgery patients to the ICU by implementing the concept of Team Resource Management (TRM) to elevate the quality of teamwork, strengthen the handover communication, ensure the accuracy and completion of exchanged information, and thereby improve patient safety and quality of care. Methods: The professional team is made up of cardiovascular surgeons, anaesthesiologists, and medical staff members in the operating room and ICU. The concept of TRM was used in the post-‐operative handover for cardiac surgery patients to the ICU. The handover process was systematically analysed and discussed to include first, using structured diagrams and an electronic handover platform to synchronise the exchanged information between medical units. And secondly, further training education system and promotion of such a handover process was implemented. Descriptive statistics were used to analyse the completion of handover checklist and the satisfaction questionnaire performed by the medical staff members. The efficacy of such strategies was evaluated accordingly. Results: The full completion of post-‐operative handover of patients to the ICU increased from 58% to 90%. The medical staff members’ understanding of patient safety also increased from 55.3% to 74%. The concept of the importance of TRM increased from 71.1% to 90.7% as well. As a result, the overall satisfaction rate elevated from 12.3% to 80.6%. Conclusion: The analysed results showed that the use of structured diagrams and electronic handover platform as tools to synchronise exchanged information using the concept of TRM has significantly improved the accurate completion of handover, understanding of patient safety, and handover satisfaction amongst the medical staff members in the operating room and ICU. This strategy intervention can therefore be expanded to be used in the handover of patients between other medical teams or units in the near future, to further strengthen the completion and the communication of handover process and thereby elevate patient safety. 1646 Combining Professional Advancement And Patient Safety: Developing A Novel Professional Certification Program For Nursing Technicians In Brazil Karina Paris* 1, Rubia Maestri2, Andreia Miranda1, Felipe Vieira Lima1 1 Hospital Moinhos de Vento, Porto Alegre, Brazil, 2Nursing Management, Hospital Moinhos de Vento, Porto Alegre, Brazil Objectives: Much of the bedside care in Brazil is provided by nursing technicians, who are not required by law to undergo professional recertification. This may directly impact the quality of patient care. Therefore, we set up a nursing technician certification program. Our initial aim was to assess staff levels of knowledge and to develop specific training in areas identified as needing improvement. Methods: All 953 nursing technicians working at the Hospital were invited to participate. Participation was voluntary. The test included a written module and a hands-‐on module referring to the specific tasks performed in each area and covering five dimensions: patient identification, medication process and patient safety, control and prevention of hospital infection, routines and procedures, and knowledge about nursing procedures. In the written evaluation, the participant was asked to answer 50 multiple-‐choice questions. For the hands-‐on test, two tasks were picked by lot and performed in a simulated environment. Chart audits evaluated the recording of information against institutional standards. For all the steps, the institution’s routines and standards, as well as legal requirements, were used as the main reference to design the questions. To become certified, participants were required to achieve a mean score ≥70 (zero to 100) considering the written and hands-‐on parts of the exam. In addition, the sum of correct answers/procedures obtained by the total nursing technicians taking the test in each hospital area was considered. If wrong answers/procedures were observed for 30% or more of the participants, the area was considered to be in non-‐conformity. Several training initiatives were provided to the entire staff in non-‐conformity areas. The staff was aware that these training opportunities had resulted from the certification program. Results: To the best of our knowledge, this is the first formal professional certification of nurse technicians in Brazil. Of 520 technicians, 94.61% obtained a score of 70. Three hundred and seven nursing technicians did not complete the three certification stages. The main reason was no-‐show (58.30%), possibly as the result of working a second job or else resistance to being tested. The highest rate of non-‐conformity was observed for the dimension “Control and prevention of hospital infection,” with 95.55% of the 45 areas being classified as non-‐conformity based on the results of hand hygiene tests. Nursing technicians who scored below 70 underwent training and took the certification exam again in the end of 2013, along with those who did not complete the three stages in 2012 and with newly hired technicians (total of 346 technicians tested). These results will be available in March 2014. Certified nursing technicians must be recertified every two years. Conclusion: The certification process helped us identify knowledge gaps and opportunities for the professional development of nursing technicians, which contributed to ensure the quality of care and patient safety. To increase the reliability of the results, greater weight will be placed on more critical and complex questions in both the written and hands-‐on tests – for example, a drug dosing error will weigh more on the final score than an error relating to the organisation of materials on a tray. 1659 Geographic Variations In Rate Of Failure-‐To-‐Rescue Among Surgical Patients: A Population-‐Based Study In New South Wales, Australia Hassan Assareh1, Lixin Ou* 1, Jack Chen1, Stephanie Hollis1 1 Simpson Centre for Health Services Research-‐Australian Institute of Health Innovation, University of New South Wales, Australia, Sydney, Australia Objectives: Failure-‐to-‐Rescue (FTR), defined as the death among surgical patients with treatable complications, is among patients safety indicators proposed by AHRQ. Reports have shown that FTR has the highest incident rate among all preventable patient safety incidents and significantly varies across hospitals, regions and nations. Such variations may reflect the successes or failures in timely recognising and responding to post-‐operative complications. However, no study had explicitly modelled the geographic variations of the FTR in a large health jurisdiction. Methods: We conducted a population-‐based study using all admitted surgical patients in public acute hospitals during 2002-‐2009 in NSW, Australia. FTR was defined as the post-‐operative deaths among patients who developed at least one of six complications including acute renal failure, DVT/PE, pneumonia, sepsis, shock or cardiac arrest, GI haemorrhage/acute ulcer. Using patients’ residential postcodes, FTR incidents were obtained and aggregated for each local government area (LGA) in NSW. Clusters of areas in which patients were exposed to a significantly higher or lower FTR risk were identified using spatial correlation indices. We employed a Bayesian spatiotemporal modelling scheme to simultaneously assess the variation of FTR rate by area (153 LGAs) and time (2002-‐2009). In a semi-‐parametric setting, a Poisson mixed model was developed to obtain adjusted FTR rate ratios (RR) with the inclusion of the geo-‐temporal interaction random effect. We also included a fixed-‐effect quadratic time trend. Results: We studied 4,362,624 elective surgical admissions in 82 acute public hospitals over eight years in NSW. Around 14% of patients who developed at least one of the six FTR-‐related complications (58,590) died during hospitalisation. Five clusters, each comprising of at least three neighbouring LGAs, were identified to have a higher or lower FTR risks (compared to the state average of 14%). Detailed analyses revealed that 34 LGAs had between 10% and 50% excessive adjusted FTR risks. They were mostly located in Sydney south and west, and Hunter New England regions. These areas accommodated 47% of all patients at risk. In contrast, 30 LGAs with lower FTR risks (RR ranged from 0.7 to 0.9) were mostly located in Sydney east and south part of NSW and accommodated 16% of NSW patients at risk. The trends of FTR which peaked between 2005 and 2006, and then declined afterwards were similar across different LGAs. Conclusion: Surgical patients residing in different geographic areas were exposed to different level of FTR risk during hospitalisation between 2002 and 2009 across NSW. A significant geographical variation was found across NSW LGAs suggesting further intervention opportunities for local health authorities. A larger proportion of patients at risk were exposed to excessive FTR risks. The decrease in the FTR rate after 2006 coincides with the establishment of national and state patient safety agencies (ACSQHC and CEC, respectively). Such a decrease in FTR was uniform across all LGAs indicating the similar positive effects on different areas from many patient safety initiatives by both agencies. 1710 Invite Caregiver Prevention Falls Reduces Incidence Of Psychiatric Patient Falls At The Medical Center In Taiwan Huang Shu-‐Wen* 1, Yan Ching-‐Yi 1, Hsieh Yu-‐Lin2, Liu Wen-‐Yu 1 1 Department of Psychiatry, 2Quality Management Center, Far Eastern Hospital, Taipei, Taiwan Objectives: Fall is always first accidents in psychiatric wards, and we've been improved it. We had through high-‐risk fall groups, adjustment drug dose, and caregiver accompany and reduced ground wet sliding, then, in 2009 to 2010 number of falls for 37 to 24, incidence of falls for 0.41% to 0.28%. In 2010 to 2012, incidence of falls for 0.26%, contrast Taiwan Clinical Performance Indicator (TCPI) peer hospital incidence of falls for 0.17%, we found have high incidence of falls and improve it. Methods: This study was conducted with Taiwan Clinical Performance Indicator (TCPI) definition to collect. In 2012, we try to understand and analysis reason of patient fall, then we found the main reason of fall was patient condition of disease, as due to attention not concentrated and patient unsteady gait, and more occurred in caregiver temporarily left. In 2013, we used method of quality improvement, and implementation three items. First, Invited caregiver or family prevention patients fall, then we would provide them knowledge of fall. Second, encourages caregiver to accompany patients especially they attention not concentrate. Finally, individualised review and improve immediately. We used descriptive statistics to analysis incidence of patient falls before and after implementation of the psychiatric ward. Results: After the implementation, number of falls for 30 to 19 in 2012 to 2013, and incidence of falls for 0.28% to 0.17%, incidence of falls reduced by 34%. Before and after the implementation, rate of injury of falls approximately 7%, and mild injuries. We also check indicator of staff invited caregiver of prevent patient fall, 100% rate of implementation. In addition to, the number of accidents has 60 to 43 in 2012 to 2013, the accident number of cases reduce by 30%. Conclusion: In recent years encourages patients participation has been core value of patients safety, through this study found invited caregiver who participation prevention fell, can effective reduced patients fell. We would continue invited caregiver prevent patient of fell in 2014, and monitor indicator of execute to improvement quality and create partners relationship between medical and family. 1733 Development And Validation Of A Hospital Safety Attitude Questionnaire In Korean And The Application Of The Empirical Bayes Method Heon-‐Jae Jeong* 1, Byung Joo Song2, Eun Ae An2, So Yeon Kim2 1 Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, United States, 2 Performance Improvement, Seoul St. Mary's Hospital, Seoul, Korea, Republic Of Objectives: Despite the national effort to improve patient safety, Korea has been lacking a validated instrument to assess safety culture in healthcare organisations; thus, the primary aim of this study was to develop and validate a Korean version of the Safety Attitude Questionnaire (SAQ-‐K). In addition, too much variation resided in some units, which impeded comparison across units in SAQ-‐K scores; therefore, we applied the Empirical Bayes (EB) method to obtain SAQ scores with higher precision. Methods: Under consent of the original developer of Safety Attitude Questionnaire (SAQ), the SAQ 2006 short version was translated into the Korean language using the back-‐translation method. Once content validity was checked by researchers, the developed SAQ-‐K was pilot tested, and four questions were excluded because double-‐negative questions in the original SAQ, once translated into Korean, were frequently misunderstood. Eventually, the SAQ-‐K was composed of 32 questions in six domains – Teamwork Climate (TC: 5 questions), Safety Climate (SC: 6), Job Satisfaction (JS: 5), Stress Recognition (SR: 4), Perceptions of Management (PM: 9), and Working Conditions (WC: 3) – and seven demographic information questions, including working area and work experience. The SAQ-‐K was administered from October 25, 2012 to November 11, 2012 in a large metropolitan hospital in Korea. Internal consistency reliability was tested using Cronbach’s alpha, and construct validity was tested through a confirmatory factor analysis (CFA) using a Structural Equation Model. We found huge variability in unit-‐level scores in some units, and therefore we applied the EB method to diminish each unit’s variability and achieve high precision in the unit mean of each domain SAQ. Results: The SAQ-‐K was administered to 1,796 health care workers (HCWs), and a total of 1,153 completed questionnaires were returned and analysed. Internal consistency measured with Cronbach’s alpha was reliable for each domain: 0.825 for TC, 0.849 for SC, 0.917 for JS, 0.766 for SR, 0.909 for PM, and 0.768 for WC. The model fit indices from CFA were also good: 0.912 for goodness-‐of-‐fit index, 0.892 for adjusted goodness-‐of-‐fit index, 0.038 for root mean square residual, 0.944 for comparative fit index, and 0.049 for root mean square error of approximation. The unit with the largest variability in TC showed a mean unit score of 86.25, and its 95% confidence interval (CI) was 65.3-‐107.2, the range of which was up to 41.9. Once the EB method was applied, the mean changed into 66.9 and the 95% Bayesian confidence interval (BCI, an equivalent of CI in EB method) was 55.0-‐78.8, whose range was only 23.8. A similar pattern of change in CIs was observed across all six domains of SAQ-‐K, allowing observation of precise unit level scores. Conclusion: The Korean translation of SAQ showed good construct validity and reliability, and this study provides evidence of the validity of the instrument. The EB method served as an appropriate approach to obtain more precise unit-‐level scores. The developed SAQ-‐K is, therefore, expected to help many Korean hospitals measure their safety attitude or culture. Caution should be exercised, however, since this study was conducted in a large metropolitan hospital; thus, future studies testing the validity of SAQ-‐K in other various healthcare settings will be of great value. 1755 A Maximum Difference Scaling Survey Of Barriers To Intensive Combination Treatment Strategies In Early Rheumatoid Arthritis Sabrina Meyfroidt* 1, Marlies Hulscher2, René Westhovens1, 3, Patrick Verschueren1, 3 1 Department of Development and Regeneration, KU Leuven, Leuven, Belgium, 2Scientific Institute for Quality of Healthcare, Radboud University Medical Center, Nijmegen, Netherlands, 3Rheumatology, University Hospitals Leuven, Leuven, Belgium Objectives: Overcoming barriers in the provision of early and intensive treatment is a key component in improving healthcare professionals’ adherence to treatment guidelines and to change practice in order to reflect current best evidence in the management of early Rheumatoid Arthritis (eRA). The primary objective of this study was to determine the relative importance of barriers related to the provision of intensive combination treatment strategies in eRA from the rheumatologist’s perspective. A secondary objective was to explore the relationships between rheumatologists’ characteristics (e.g. gender, work experience, type of clinical setting) and importance scores. Methods: A Maximum Difference Scaling (MDS) survey was administered to 66 rheumatologists in Flanders. The survey included 25 barriers, previously being discovered in a qualitative study. The MDS included 25 choice sets, each of which contained a different set of 4 barriers. In each choice situation, respondents were asked to choose the most important barrier. The mean Relative Importance Score (RIS) for each barrier was calculated using hierarchical Bayes modelling (Sawtooth Software's SSI Web platform, version 8.2.0). The potential relationships between characteristics of the rheumatologist and the RIS was examined (Spearman’s correlation coefficient, Mann-‐Whitney U test and Kruskal-‐Wallis H test; Statistical Package for Social Science [SPSS] software, version 20.0). Results: The 8 most important barriers were: 1) contraindications for certain patients; e.g. patients with comorbidities, older patients (mean RIS 9.8); 2) an increased risk of side effects and related complications (mean RIS 8.5); 3) having to deal with patients’ resistance (mean RIS 7.5); 4) the requirement to prescribe glucocorticoids (GCs) for 28 weeks (mean RIS 7.3); 5) the inability to objectively assess side effects and/or the effectiveness of the individual compounds of the combination scheme (mean RIS 7.1); 6) the requirement to prescribe > 10mg GCs as the initial dose (mean RIS 6.5); 7) lack of clear practical ( inter)national guidelines (mean RIS 5.9); and 8) the required investment for patient education (mean RIS 4.9). No significant relationship between rheumatologists’ characteristics and importance scores was found. Conclusion: Concerns regarding the suitability of intensive combination treatment strategies to the individual patient and fear of increased side effects and related complications were the most important barriers for all rheumatologists. Interventions to facilitate the provision of intensive combination treatment strategies in daily practice, following current best evidence regarding the management of eRA, should focus on physicians’ familiarity with the treatment strategies and patient education. 1765 To Achieve 100% Discharge Of *Appropriate Elective* As 23 Orthopaedic Patients Before 1,000Hrs Within 6 Months * 1 1 Alicia S. P. Chang , Kim Yan Lim 1 Operating Theatre Service, Tan Tock Seng Hospital PTE LTD, Singapore, Singapore Objectives: To be able to discharge 100% of *appropriate elective* As 23 Orthopaedic patients before 1,000hrs within 6 months. *Ambulatory Surgery 23 hours (AS23) is an admission type whereby the “selected patients” will stay overnight in Day Surgery Centre. Methods: Day Surgery Centre is an admitting centre for all elective surgeries, handling multidiscipline cases, e.g. General Surgery, Orthopaedic, st Ophthalmic and etc. The centre served a total number of 24 operating theatres daily with 1 case starting from 8am to 8.30am, and almost all the 24 patients are required to be admitted at 7am in order to start surgery timely at 8am. Majority of the patients are required to report to an hour before surgery and as for Ophthalmic cases, the surgery time turnover rate is much shorter and faster, hence patients are scheduled for surgery at 15 to 20 minutes interval, as such; there are approximately 35 to 45 patients to be admitted between 7am to 9am daily to meet the daily demand. Cases whereby AS23 patients are begin to stay overnight in the centre, ranging up to 25 patients daily and these group of patients do not required inpatient admission to the general ward post operatively. There are 41.3% of AS23 orthopaedic patients discharged before 1000hrs as shown from data collected and for these group of patients that are not discharged timely by 9am, DSC will face an increase in demand of bed space as post operatively patients starts to return back from operating theatre’s well as on-‐going new admission of cases for surgery. Staff need to allocate beds to the new admissions, occasionally may be required to plan and spent time to shuffle beds to accommodate the patients for surgery. Late discharge can also lead to unhappy and dissatisfied patients/family members. Method: Using Methodology from Clinical Practice Improvement Programme, the team was formed with 1 orthopaedic doctor, 2 nurse clinicians, 1 staff nurse, 1 physiotherapist, and 1 orthotist. A cause and effect diagram was done to analyse the problems and four main root causes were identified in the Pareto chart: a) b) c) d) Long ward rounds in inpatient ward resulting in late reviewed by doctors Unable to complete physiotherapy prior to discharge by 10am Waiting for relative to fetch patient home Nursing staff too busy Plan-‐Do-‐Study-‐Act (PDSA) cycle was conducted and interventions were carried out with the support orthopaedic HOD Mr. Ganesan together with Operating theatre orthopaedic nursing officers and staffs. Results: After one month of interventions, there were an increased in percentage of discharging patients before 1000hrs to 65%. Physiotherapy remained the main reason in causing delayed in discharging patients, as each physiotherapy session with patient took 45 minutes to 1 hour. Discussions were carried out periodically with physiotherapist to improve the workflow. Further interventions were implemented; subsequently there was an improvement from 65% to above 70%. ! The patients and relatives were satisfied as patients are able to discharge on expected time. ! It also improves staff morale, as more quality time can be spent with other patients. Conclusion: A keyed lesson learnt was that it requires synergy from various professionals. Members need to discuss and share different points of views which it requires great understanding from all members and most importantly the support from the HOD. Although we have not achieved 100% to discharge patients before 1000hrs, but we have achieved greater cooperation and collaboration between physiotherapist and the nursing staff in the ward 1799 Involving The Family In The Adherence To Hand Hygiene (HH): A Multi-‐Disciplinary Study With Playful Strategies Melina B. Amarins* 1, João F. Almeida2, Arlei A. Silva2, Simone Brandi2 1 Pediatria, 2PICU, Hospital Israelita Albert Einstein, São Paulo, Brazil Objectives: 1) Evaluate whether educational and playful strategies with staff and family contribute to increase the compliance of hand hygiene. 2) Increase by 10 % adherence to hand hygiene by the multidisciplinary team. Methods: Hand Hygiene is considered a simple and primary measure in the control of nosocomial infections, including those resulting from cross-‐transmission of multi-‐resistant microorganisms. In despite of the health professional knowledge of the subject, the adherence of HH remains low. In our hospital, after annual unit audit of HH performance and continuous training about the WHO’s five moments of HH, the result was 63.6% of adherence of the multidisciplinary team. Despite being an adherence above world literature (40%), the target in our hospital is 70%. No scientific evidence was found on the involvement of family to increase the efficacy of HH. The study was conducted in the 15 bed Paediatric Intensive Care Unit (PICU) of Albert Einstein Hospital. The study had four moments: 1) Two hour re-‐training of all the multidisciplinary team on the WHO’s five moments of HH. 2) Development of large colourful cards by the toy librarian team of the Paediatric Playroom for children, with the goal of alert health professionals to remember about HH before handling the patient. 3) Perform a parent’s survey to verify the patient and parent understanding of the benefits of the project. 4) New audit for assessing adherence to hand hygiene. Results: 38 patients were included. These actions have improved the outcome of adherence to HH in PICU, totalling 81.3 % (increase of 21.7% compared to the previous audit). About survey results, we found that 89 % understood the proposed action, 100% of the families felt comfortable and believed that such actions contribute to better compliance of HH and 89% reported that they observed a beneficial effect in the multidisciplinary team after intervention. Strategies added to the behavioural training and family involvement improved the results of adherence to HH. It was found that game strategy facilitated family participation in the process and their involvement in HH. Conclusion: The 10% target was achieved, reaching an increase of 21.7 % in adherence. We concluded that educational and playful strategies with staff and family contributed to increased adherence to hand hygiene. 1806 Implementing An Electronic Medication Overview In Belgium Hannelore Storms* 1, Kristel Marquet1, Neree Claes1 1 Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium Objectives: Digitally sharing information enables improved communication, consequently increasing accuracy of a medication overview, resulting in reduced medication errors [1]. The aim of this study is to evaluate implementation of an electronic medication overview, particularly its accessibility and usability. Methods: In Belgium a project called “Vitalink” was implemented. Main objective of this project was to improve the exchange of health information between healthcare professionals as well as towards patients. Software packages generating an electronic medication overview out of patients’ health records were developed. The generated medication overview listed all prescribed medication with name, dose, frequency, way of administration and moment of intake. Because data is transferred over the Internet, a lot of thought went into secured data transfer and authorised access. Security is guaranteed by: encoding health information as well as encrypting the encryption key; two separate decoding keys; registration of all actions performed on the data. Access is granted only to those healthcare professionals selected by the patient through an informed consent. To check authorisation healthcare professionals’ and patients’ identities are verified by reading their e-‐ID using an e-‐ID reader. This e-‐ID reader is linked to one’s computer, connected to the Internet. When authorisation is approved, there are still restrictions as to the actions that can be performed on the data, depending on the type of healthcare professional who’s accessing the medication overview. General practitioners and pharmacists can consult and change the medication overview whereas nurses, home care staff and secondary caregivers can only consult it. The patient as well can only consult the electronic medication overview. Expectations of general practitioners, pharmacists, nurses, home care staff and secondary care professionals of four regions in Belgium were documented using an online survey at the start of the project. Complementary findings were gathered by the coordinating teams. Enrolment of healthcare professionals was voluntary. To obtain medical information, patients granted access to participating healthcare professionals through informed consent. Only records of patients meeting the following criteria were eligible: being prescribed minimum 3 different, chronic drugs and having signed an informed consent. Residing in a nursing home is an exclusion criterion. The study was approved by the Ethics Committees of the Universities of Hasselt and Antwerp. Data were analysed by one researcher using SPSS 20.0. Results: A total of 263 healthcare professionals filled out the survey. Nurses represented the biggest group (55.6%). Most healthcare professionals perceived patients’ compliance to be “moderate” and perceived themselves as “sometimes” detecting medication errors. Healthcare professionals’ expectations about barriers regarding the implementation are: an administrative burden (because of the setup of the software and the follow up of the project) and problems with maladjusted software. Conclusion: A successful implementation of an electronic medication overview highly depends on the accessibility and usability of the tool. This means that there’s a need for secured and quick access to medical data. Secondly, software should meet the needs of its users, adapted to daily activities of healthcare professionals. References: 1. Hillestad R, Bigelow J, Bower A, et al. Can electronic medical record systems transform health care? Potential health benefits, savings and costs. Health Aff. 2005; 24:1103–17. 1833 Re-‐admission Rates As A Quality Indicator: A Systematic Review Of Methodological Conditions And Scientific Evidence On Validity Claudia Fischer* 1, Hester Lingsma1, Ewout Steyerberg1, Dionne Kringos2 1 ERASMUSMC, Rotterdam, 2AMC, Amsterdam, Netherlands Objectives: Hospital re-‐admission rates are increasingly used as an indicator for hospital quality. However, different methodological aspects in the definition and measurement of readmission rates need to be considered when interpreting these rates as a reflection of quality of care. The aim of this study is: 1) to give an overview of the methodological conditions that need to be considered when calculating re-‐admission rates; and 2) to discuss the impact of these conditions on the validity of re-‐admission rates as a hospital quality indicator, specifically when used for benchmarking hospital performance. Methods: We conducted a systematic literature review, using the bibliographic databases Embase, Medline OvidSP, Web-‐of-‐ Science, Cochrane central and PubMed for the period of January 2001 to May 2013. Results: Review of 1616 papers showed that definition of the context in which readmissions are used as a quality indicator is crucial. This context includes the quality dimension aimed to assess and the patient group under investigation. Next, the following methodological conditions may confound the comparison between hospitals based on readmission rates: data reliability, insufficient case-‐mix correction and unspecific definitions. Finally, the multi-‐faceted nature of quality of care and the correlation between readmissions with other outcomes, such as death, limit the indicators validity. While some of the discussed factors could in principal be improved by investing resources in accurate data registry and refinements of indicator description, other problems, like aspects of the competing endpoint mortality, are more complex to solve. Therefore, bringing outcome measures into relation to each other provides a more global picture of hospital care. Conclusion: A number of methodological conditions need to be fulfilled when using readmission rates as quality indicator, for external quality purposes, or for pay for performance. 1866 Improvement Of Surgery Preparation Process And Indication Of Correct Surgery Site Of Orthopaedic Surgery Patient To Prevent Wrong Site Surgery Ki Sun Seong1, Mi Ja Ju1, Hyun Jung Oh1, Ga Lam Choi* 1 1 Samsung Medical Centre, Seoul, Korea, Republic Of Objectives: Every Orthopaedic Surgery (OS) needs a clear indication of surgical site due to diverse nature of surgical locations. Thus indicating the correct surgical site and adequate preparation of surgery is very important. In 2012, out of 6008 OS surgery cases, there were 117 cases (1.95%) of missed or incorrect indication of surgical site on the surgery consent form, and 977 cases (16.2%) of no indication of surgical site on patient's body. Even with the indication of surgical site, 1759 cases (29.3%) were not under Samsung Medical Centre (SMC) guidelines. Also, there were 3 cases of surgery preparation of wrong surgical site. Since incorrect surgical site indication and surgery preparation can cause fatal damage to a patient, an improvement of process in correct indication of a surgical site and surgery preparation is needed. To prevent medical accident such as wrong site surgery of OS patients through improvement of process in correct surgical site indication and surgery preparation. 1) Zero cases of dropped or misindication of surgical site on surgery consent form 2) Zero cases of misindication of surgical site and not following of SMC guideline on surgical site indication 3) Zero cases of surgery preparation of wrong surgical site Methods: 1. There is no surgical site heading in consent form. Patient, he/she, is not aware of his/her surgery site. Thus, surgical site double check is required when signing consent form. Add 'surgical site' heading among diagnosis/surgery headings of consent form. Provide space for patient's signature of 'surgical site' on consent form. 2. Standardisation of surgical site indication is needed. Diverse way to indicate surgical site by different medical personnel should be standardised under guideline. Education of such guideline is required. Develop standardised guidelines on surgical site indication depending on type of surgeries. 3. A new process which medical team members can double check the surgical site during surgery preparation is needed. Add a double check process of surgical site. Results: 1) 0 cases of dropped of misindication of surgery site on consent form (2013/9/23~2013/9/30)-‐48 type of OS surgery consent form were used since 2013/9/23 2) 968 cases on dropped surgery site indication compared to 2012. (2013/7/1~2013/9/30)-‐0 cases of not following the guideline on surgical site indication. (2013/7/1~2013/9/30) 3) 0 cases of surgery preparation on wrong surgical site.(2013/3/1~2013/9/30) Conclusion: 1. Improvement of surgical site indication and preparation process, we could prevent wrong site surgery. 2. Surgical site indication of I&D patients were unsatisfactory. More education is needed. 3. Application of improved OS consent form such as adding surgical site heading among diagnosis/surgery, on other departments' and standard consent form should be considered to promote better patient safety. References: (1) Donna S. Watson. Sentinel events. Aorn J.2009:90(6);926-‐929. (2) Mary Blaco, John R. Clarke, Denise Martindell. Wrong site surgery near misses and actual occurrences. Aorn J.2009:90(2); 215-‐222. (3) Peri-‐operative Standards and Recommended Practices, 2013 Edition 1875 Risk Evaluation Of Errors Arising From Patients Identification In An Obstetric Unit Of A Teaching Hospital Terezinha H. Tase* 1, Daisy M. R. Tronchin2 1 Clínica Obstétrica, Hospital das Clínicas da Faculdade de Medicina da USP, 2Escola de Enfermagem , Universidade de São Paulo, São Paulo, Brazil Objectives: To determine the frequency of similarity in names and hospital registry number and to quantify the risk for misidentification in patients admitted at the Obstetric Unit in a teaching Hospital. Methods: This was a descriptive study involving 2168 hospital admissions during October 2012 and September 2013. Data from hospital records (name, date of admission, hospital registry number, bed number, date of hospital discharge) were used for analysis. Statistical analysis of risk categorisation was made by deriving an algorithm for text comparison to soundex for names and hospital registry numbers. Results: Similarity was observed in 75.1% for the first name, 81.5% for the surname and 18.5% for the full name. The frequencies to similar-‐sounding were 91.2, 89.2 and 31.5 for first name, surname and full name respectively. Regarding to calendar period, the higher incidence of similarities between names and surname (17.5%) occurred during the first week of December 2012, and when analysed by the soundex, the incidence in this period increased to 29.5%. Furthermore in this period 2.1% of women at risk stayed in the same hospital room during three days. Conclusion: In our Obstetric Unit we observed similarities in names and sounding names. Similarities were mainly present for surname and for name sounding. Therefore the study demonstrates the need to call patients by their full name in order to reduce the risk for errors in health care assistance. 1878 Operational Safety Program Based On Human Factors Approach: The Proposal Of A Model For Critical Care Units Haggeas Fernandes* 1, Elizabete Cazzolato1, Valter Carneiro2, Raquel Pusch3 1 Critical Care Unit, Hospital Brasil, Santo Andre, 2Human Factors, Gol Linhas Aereas, Sao Paulo, 3Psicologia, Hospital Vita, Curitiba, Brazil Objectives: Operational safety is a major concern in Critical Care Units (ICUs). The human factor plays an important role in daily ICU routine and is involved in errors that can cause harm involving an impact on outcome of critically ill patients. Our objective is to describe the design of a feasible safety program model, based on human factors approach, which involved the coaching of an air flight company, and can be applied in ICUs, with five domains: approval and support of the leadership; assess the safety culture; train healthcare workers with non-‐technical skills; audit and improve the ICU operational routine; prevent, analyse and mitigate threats and errors, with an Adverse Event Analysis Protocol (AEAP) and preventive measures; a family approach team, with a Patient Centered Care (PCC) management model. Methods: The program was based on the LOSA system (Line Operational Safety Audit), CRM (Crew Resource Management) training from the airline industry and PCC model. Contrasts between healthcare and aviation was discussed and characterised, allowing the program customisation to ICUs. Firstly, a study of economical and technical feasibility was conducted, for submission and program approval. A sequence of 5 domains was developed, as a bundle to be implemented in ICUs, with the aim of improving safety and guiding the team clearly. The implementation followed this framework: ! ! ! ! ! Meeting with the executive office to show the program relevance and obtain support to implement Assessment of current safety culture through a survey (Likert scale method) Establishment of the risk management ICU team to execute the program planning Creating the family approach team to PCC program Providing the Crew Resource Management training with specific skills for healthcare workers Results: The program was approved by the Institute of Education and Research and the executive office of Hospital Brazil, Santo Andre, Sao Paulo, a tertiary hospital with 80 ICU beds. After meetings with human factors aviation professionals, we created a CRM training for healthcare workers, based on non-‐technical skills and the just culture concept. In parallel, we initiated the development of a Safety Attitude Questionnaire (SAQ) which was introduced in November 2013 and completed by 150 ICU employees. The data obtained from the SAQ were evaluated and shown after the CRM training for ICU professionals. The AEAP was introduced in the ICU routine in May 2013, after the execution of a pilot project. The ICU CRM training was conducted, after 9 months of development (December 2013), to 50 ICU employees, as a pilot project with the proposal to continue in 2014. The family team was created and trained with specific negotiation skills and preventive family meetings. The next step will involve the collection and analysis of data, to evaluate the program's impact on patient outcome and reduction of near misses and adverse events. Conclusion: This safety operational model is feasible to be implemented as a multifaceted intervention, and can provide a competitive advantage for ICUs as a tool to reduce operational risks and probably costs. The implementation and program success depends strongly on a human factors and risk management specialised team, which holds the expertise for such program. References: 1. Kanki B, Helmreich R, Anca J. Crew Resource Management, 2º Edition, Elsevier 2010 2. Davidson J, Powers K, Hedayat K et al. Crit Care Med 2007;35:605-‐622 1893 Minimising The Waiting Time During Discharge To Achieve More Effective Use Of Patient Beds Jui-‐Ling Hung* 1, Yun-‐Hsiu Hung1, Xiu-‐Fang Wu1 1 Nursing Department, Landseed Hospital, Taoyuan County, Taiwan Objectives: Because the implementation of National Health Insurance program and growing consumer awareness, patient’s expectations on the quality of health services continue to increase. To ensure the best interests of patients and their families, the Article 1.7.7 of newly revised regulations of Taiwan Hospital Accreditation states that the patient discharge process plan should be regularly reviewed to consolidate proposal for a continuous improvement. The Article 1.7.8 also emphasises the importance of effective uses of patient beds in hospitals. Both tasks are recognised measures of the quality indicators for healthcare services. Base on the objective to promote patient satisfaction in our hospital, a total of 1,162 cases of patient discharge in February 2012 were analysed. There were 379 cases spent longer than 120 min from printing out a prescription order to the completion of payment process, accounting for 32.6%. The average time length of processing was 138 minutes. An average of 80 min was required to print out and receive a prescription order, which was much longer than the acceptable time length for the discharged patients interviewed. The results indicated that longer waiting time was associated with lower patient satisfaction. Consequently, it could lengthen the waiting time of admission for other patients and reduce the effectiveness of patient care. Methods: 1. The discharge processes were defined as the following: providing discharge prescription, discharge prescription undertaken by nurses, printing out of hospital billing statement, and payment processing undertaken by patients. The problems of all processes were identified and targeted for improvement. 2. Define the improvement strategies 3. Identifying the patients to be discharged and ensuring the discharge prescriptions are written on the next day for patient in order to shorten the waiting time. 4. Completing the processes of discharge prescriptions and medical orders by 9:00 am every day. 5. Completing the procedure of printing out prescription and hospital billing undertaken by nurses within 60 minutes. 6. Completing the inpatient payment process by 10:00 am. 7. Monthly monitoring and follow-‐up review the time length of discharge process. Results: After implementing this project, the average time length of hospital discharge process from prescription to the payment being completed was reduced from 130 min to 70 min (the target time length was 120 min). The results indicated that the improvement rate was 49% and the target rate reached to 377.7%. As such, this project was continued in 2013. Conclusion: The establishment of a mechanism for collecting and analysing information should be also necessary for patient-‐ centered healthcare services, including accessible registration, hospital admission and discharge, waiting, payment and cashing process and other services. Patient satisfaction can be increased by minimising waiting time and improving service quality. In addition to effectively improve the turnover rate of patient beds, hospitals can establish a good corporate image by using monitors to collect information on process flow for labour cost reduction, instead of manual login. 1903 Improvement Of The Exacerbation Of Patients With COPD By Identifying And Correcting The Technique Of Hui-‐Chen Hsieh* 1, Chih-‐Hao Chao1, Yi-‐Chou Chiou1, Shu-‐Hui Yeh1 1 Medical intensive care unit, Chang Bing Show Chwan Memorial Hospital, Changhua,, Changhua County, Taiwan Objectives: Patients with COPD are prone to exacerbation of respiratory distress. In order to lower the exacerbation risk of the patients with COPD, we sought to identify the misuse of hand hold inhalers for disease control and to correct the misuse and to improve the technique of hand hold inhaler. Methods: Misuses of hand hold inhalers in COPD patients were assessed before intervention. After identifying the misuse of hand hold inhalers, a teaching video demonstrating the technique of the soft mist inhaler and dry power inhaler step by step in Taiwanese language was introduced. After intervention for one month, hand hold inhalers technique was assessed using a standardised inhaler-‐specific checklist. A combined COPD assessment with pulmonary function test plus COPD assessment tool (CAT) was used to assess the risk of COPD exacerbation and disease characteristics Results: Twenty eligible participants were enrolled. The most frequent misuse of inhalation techniques was “failure to hold their breath after soft mist inhaler for Tiotropium (69%) and dry power inhaler for Seretide Accuhaler (89%)”.The second most frequent misuse was “failure to exhale before inhaling through soft Mist inhaler (62.5%) and Seretide 250 Accuhaler (89%); After one month intervention, the misuse rate significantly decreased on hold their breath after inhaling through soft mist inhaler (6.3%) and Seretide 250 Accuhaler (22.23%). The misuse of exhale before inhaling also decreased on soft Mist inhaler (0%) and Seretide 250 Accuhaler (22.3%). Overall, the correct use of (tiotropium) soft mist Inhaler improved from 74% to 91%; the correct use of Seretide 250 Accuhaler improved from 73% to 94%. The status of disease control of COPD approached more stable after intervention. The risk of grade B COPD exacerbation significantly decreased from 60% to 18%, and the risk graded D COPD exacerbation decreased from 30% to 25% Conclusion: Symptoms of the COPD patients could be significantly improved by identifying and correcting the technique of inhalation medication. A check-‐list of the techniques of hand hold inhalers is a good way to make sure the correction of inhalation and better control of COPD. To prevent misuse of hand hold inhalers and COPD exacerbation, it is imperative to regularly assess and reinforce correct inhalation techniques in COPD patients by well-‐organised professionals. 1914 Clinical Laboratory Job Safety/Hazard Analysis Regarding Charcoal Mask Usage In Collection Points For Formaldehyde Sohail A. Baloch1, Natasha Ali1, Muhammad Ahmer* 1 1 Clinical Lab, Aga Khan University and Hospital, Karachi, Pakistan Objectives: To check the Short Term Exposure Limit (STEL) of Formaldehyde. Based on the results obtained we will decide whether Charcoal mask is needed at our collection points if it exceeds two parts formaldehyde per million parts of air (2 ppm) as a 15-‐minute STEL. Methods: The first step was to check the volume of formaldehyde in a specimen received for biopsy followed by addition of formaldehyde if the quantity was insufficient. Entry RAE Gas detector was used to take readings in the initial 15 minutes every hour for eight hours. Results: We conducted fifteen studies in different collection points. In all cases no reading crossed the upper limit which was >2.0. Conclusion: All our readings remained well within the acceptable range; therefore there was no need of charcoal mask in our collection points. References: A short-‐term exposure limit (STEL) is the acceptable average exposure over a short period of time, usually 15 minutes as long as the time weighted average is not exceeded. STEL is a term used in occupational health, industrial hygiene and toxicology. In United States STEL of a chemical has been defined as legal limit for exposure of an employee to a chemical substance. The Occupational Safety and Health Administration (U.S. OSHA) has set OSHA-‐STELs for chemicals. STEL assessments are usually done for 15 minutes and expressed in parts per million (ppm), or sometimes in milligrams per cubic meter (mg/m3). 1925 How Do Individual And Organisational Factors Impact The Relationship Between Clinician Burnout And Patient Safety? Annalena Welp1, Tanja Manser* 1 1 Department of Psychology, University of Fribourg, Fribourg, Switzerland Objectives: The aim of this study was to examine differences in the strength of the relationship between clinician burnout and patient safety by including individual and organisational moderators. Maintaining clinician’s health and ensuring safe patient care are important goals for hospitals. Previous studies have shown that these domains are not independent from each other. For instance, stressed clinicians perceive their working environment as less safe for patients and report more errors. However, the role of individual and organisational moderators of this relationship is not clear and was thus the focus of this study. Methods: Participants were 1453 physicians and nurses working in 58 intensive care units. Moderation analysis was used to investigate the effect of individual (e.g. professional experience, unit tenure) and organisational (e.g. professional group, hospital type) characteristics on relationships between emotional exhaustion, depersonalisation and professional accomplishment and patient safety ratings; we controlled for gender. Results: Patient safety was associated with all burnout dimensions. Contrary to our expectations, professional group did not moderate these relationships. Results were heterogeneous with regard to moderators such as degree of employment or professional position. Unit tenure and professional experience moderated the relationships between patient safety and burnout. Burnt-‐out, junior clinicians with low unit tenure rated patient safety lower than when they were not burnt out, whereas burnout did not play a role in safety ratings for experienced clinicians with high unit tenure. Conclusion: Patient safety ratings and burnout in junior clinicians are not independent from each other. For the final paper, we will expand the analyses with objective patient safety data (e.g. standardised mortality ratios). More profound knowledge of characteristics that have an impact on the relationship between patient safety and burnout could help manage them simultaneously. 1964 What Can We Learn From A Decade Of Patient Safety Incident Reports? A Quantitative Analysis Of The National Reporting And Learning System Data Ann-‐Marie Howell* 1, Elaine Burns1, Thanos Athanasiou1, Ara Darzi1 1 Surgery and Cancer, Imperial College London, London, United Kingdom Objectives: Since 2003 the National Reporting and Learning System (NRLS) has collected reports about patient safety incidents in England and Wales. The reporting system's objectives were to monitor and learn from errors in healthcare. This study aims: 1. To examine how well the NRLS is able to monitor error rate and what hospital characteristics correspond with high reported rates of patient safety incidents. 2. To examine the quality of data collected since inception and assess what we can learn about patient safety and reporting over the last decade. 3. To propose methods for increasing the learning from the current system. Methods: This study used a mix methods approach for assessing the data. Hospital structural, process and outcome factors were correlated with institutional reporting rates over one year to examine what factors influenced reporting. The whole dataset was assessed for completeness. The classification system used to categorise types of error was assessed for sensitivity and specificity and ambiguity. The data were investigated using Pareto analysis and regression models to establish which patients are most vulnerable to reported harm. Staff survey findings regarding hospital safety culture were correlated with reporting rates in order to understand what barriers there are to error disclosure. Results: 5,879954 reports were collected from hospitals over the decade. The median number of all patient safety incidents reported per 100 admissions=5.87 (Inter-‐quartile range=2.06). Hospital structural factors such as teaching hospital status, bed numbers and staff ratios did not significantly influence reporting rate. The ratings that patients gave their hospital care on a national patient survey did not correlate with reporting rate. Standardised Hospital Mortality Index ratings weakly correlated with reported death (r=0.16, p=0.05). Litigation claims did not correlate with overall reporting rate [r=-‐0.13 (p=0.19)] or death rate [r=-‐0.04 (p=0.70)]. Correct system classification of type of harm gave a receiver operating characteristic area under the curve of 0.61(95%CI 0.58-‐0.63) (p<0.001). 59.8% of reports relate to elderly patients and 50.5% pertain to patients treated in medical specialties. 70.3% of reports were near misses. Only 0.9% of reports pertain to severe harm or death. Obstetrics and gynaecology reported the most near misses [OR 1.61(CI: 1.12-‐2.27) (p=0.009)] and pharmacy was the hospital location where most near misses were captured [OR 3.03(CI: 2.04-‐4.55) (p<0.001)]. Doctors were significantly more likely to report death than other staff [OR 3.04(CI: 2.43-‐3.80) (p<0.001)]. Staff survey responses revealed that keeping reports confidential, keeping staff informed about incidents and giving feedback on safety initiatives: increased reporting rates [r=0.26 (p=0.001)], [r=0.17 (p=0.04)], [r=0.23 (p=0.01)], [r=0.20 (p=0.02)]. Conclusion: The NRLS is the largest patient safety reporting system in the world. There is variation in the rate of reported errors but there were no structural, process or outcome characteristics found to strongly influence reporting. Reports continue to reflect healthcare professional’s’ concerns regarding their patients, and those consistently most vulnerable to reported harm are elderly, medical inpatients. The data quality has potential for improvement in order to improve specific, anonymous feedback and learning, which are key issues found by staff surveys that increase reporting. We believe that through maximising the data mining, there is great scope for increased learning from this valuable resource. 1977 Implementation Of A New Change-‐Of-‐Shift Report Model For Improvement Of Handoff Communications Karina Paris* 1, Elisangela F. Melo1, Daniela Oliveira1, Rubia Maestri1 1 Hospital Moinhos de Vento, Porto Alegre, Brazil Objectives: The change-‐of-‐shift handoff, or handover, is a mechanism used by nursing staff to ensure the continuity of patient care. It constitutes an essential activity in the organisation of clinical work, whereby information is conveyed from the providers who are finishing a shift to those starting the next shift. This information covers patient status, treatment, care provided, complications, pending issues, and facts specific to the inpatient unit that warrant attention. Handoff communications can be organised in a variety of ways. Our aim is to describe the implementation of an electronic change-‐of-‐shift report at Hospital Moinhos de Vento. Methods: This is an experience report describing the work developed as part of the first author's traineeship project. Working together with the Hospital's IT department, we designed an electronic change-‐of-‐shift report, seeking to include relevant information from the electronic medical record as well as information that could be entered by the shift nurse. A 7-‐day pilot project was conducted at a 36-‐bed cardiac and neurological inpatient unit. The night nurse updated the report, which was started by the morning nurse. Results: The average handoff time, which previously exceeded 15 minutes, was reduced to 10 minutes with the new methodology. As pilot implementation of the electronic change-‐of-‐shift report was successful, we expanded it to all inpatient units. The change-‐of-‐shift handoff gained significance and helped streamline care, due to the communication of knowledge on the individualities of each patient (e.g., condition and treatment) and concise exchange of relevant patient information. Implementation of the electronic report also reduced side conversations among providers, as well as the number of times team members left their stations to address pending care issues Conclusion: The implementation of an electronic report with daily data input improved the quality of the time devoted by nurses to patient handoff, increasing the reliability of this activity while maintaining the communication of relevant information about each patient. 2012 Evaluation Of Implementing A Standardised Innovative Rapid Response System In Australian Hospitals Stephanie J. Hollis1, Jack Chen1, Hassan Assareh1, Lixin Ou* 1 1 Simpson Centre for Health Services Research, Australian Institute of Health Innovation, Faculty of Medicine, The University of New South Wales, Sydney, Australia Objectives: The Between The Flags (BTF) program was a state-‐wide initiative by the NSW Ministry of Health, implemented across New South Wales (NSW) hospitals in 2010, aiming to improve early recognition and response to the clinical deterioration of patients. The BTF program implementation involved the introduction of a standardised two-‐tier system including both a clinical review and a rapid response tier. This study aimed to evaluate the implementation of the BTF program and identify the potential barriers and facilitators to implementing such a system. Methods: Just under 100 NSW hospital staff participated in the qualitative study, involving 11 focus group sessions and two one-‐ on-‐one interviews across 13 different hospital facilities (10 hospitals and 3 rural remote sites) between November 2012 and June 2013. Each hospital provided 8-‐11 staff members inclusive of at least one of each in the role of nurse, nurse unit manager, hospital manager, executive staff member, ward doctor and rapid response team member. Author 1 conducted the 90 minute sessions using broad based questions to explore staff perspectives about the implementation of the BTF program. A focus group guide was used to ensure consistency in protocol, and in questions and discussion topics. Preliminary themes were derived from each focus group transcript followed by the collapsing and combination of preliminary themes until each final theme clearly represented a single and complete concept. Results: The main facilitators and enablers to the success of the BTF program implementation were clinically based. Staff in all roles felt that the addition of a clinical review tier to the rapid response tier improved early recognition and response to the clinical deterioration of patients, and that it improved overall patient safety. The main implementation barriers reported by staff ranged from unrealistic implementation timeframe; lack of staffing or resource support for facilitating and integrating the relevant changes required for each varying hospital system; lack of time provision for staff education and training, through to hospital culture aspects such as staff non-‐compliance, particularly involving doctors. Conclusion: The BTF program has generally been received positively across the state by NSW hospital staff. Eight key themes emerged from this study indicating the potential for further improvement to patient outcome. While staffing pressure remains an issue, the empowerment of nurses and use of common terminology has improved communication and interaction between nursing staff and ward doctors. The majority of staff were in agreement that the BTF program improved overall patient safety. However, they also felt that it still lacked the funding support to provide adequate staffing and resources to achieve the intended patient outcomes of reduced cardiac arrests and hospital mortality in NSW hospitals. 2035 Using A Computerised Barcode System For Surgical Instrument Packs To Enhance Instrument Management Ju H. Jen* 1, 1, Ying C. Huang1, Mei Y. Chuang1, 1, Wei Y. Huang2 1 Nurse Department, 2Materials Department, Far Eastern Memorial Hospital, New Taipei City, Taiwan Objectives: In order to ensure the sterilisation quality of supply centers, management efficiency should be increased and operational costs should be reduced. Moreover, the use of information systems can be combined to establish a barcode system process management for surgical instrument packs in order to guarantee the safety of surgical patients. Methods: In order to shorten the time expended in finding packs, to effectively prevent the re-‐sterilisation of expired packs, barcodes were used to computerise the manual usage of instrument packs in 2012. 1) A barcode system for instrument packs was established. 2) Process management for surgical instrument packs was established. 3) Supply centers and operating room in-‐service training was promoted. Since January 2013, the computerised barcode system for instrument packs has been used to compare the differences between manually searching for instrument packs and expired instrument packs and using the computerised barcoding. Statistical data from January to August 2013 were used for analysis, with findings showing a total of 254 types and 487 numbers of surgical instrument packs in the hospital. Approximately 3,344 packs are supplied each year for surgeries. Instrument packs are controlled during surgeries. An average of 120 packs is searched for manually each month. The average work time expended for each pack is 15.4 minutes, with a total of 30.8 hours per month. An average of 20% of an employee’s workload is required each month. Using the average monthly salary of NTD 38,133 for the hospital in 2013, the cost for this workload is NTD 7,626.6/month. An average of 430 packs of expired instrument packs are searched for, with the average work time expended being 21.8 minutes per pack, which adds up to a sum of 156.2 hours per month. An average of 90% of an employee’s workload is required each month, for a workload cost of NTD 34,319.7/month. Results: The following improvements to December 2013, The results showed that: 1) An average working time of 7.7 minutes per pack was expended in searching for instrument packs, which is 7.7 minutes less time than required with manual searching. In terms of the service amount for the same period, the working time expended was 15.4 hours/month, which is 15.4 hours/month less time than was required before improvements were made. The average percentage of an employee’s workload required per month was 10%, which was a decrease of 10%; and the workload cost was NTD 3,813.3/month, which was a decrease of NTD 3,813.3 compared to the NTD 7,626.6 required for manual searching. 2) After the improvements, the average work time required for searching for expired instrument packs was 11.2 minutes, for a total of 80.3 hours/month, which is76.0 hours less than the time required for manual searching. The average percentage of an employee’s workload required each month was 40%, which is 50% less than was required before the improvements. The workload cost was NTD 15,253.2/month, which is NTD 19,066.5 less than was required for manual searching. Conclusion: The use of a computerised barcode system for instrument packs clearly controls the direction of instrument packs. If problems occur in sterilisation, the patient on whom an instrument that had not been properly sterilised was used can be immediately tracked so as to reduce the damage caused to the patient to a minimum. References: Esptein, R. H., & Dexter, F. (2000). Economic analysis of linking operating room scheduling and hospital material management information systems for just-‐in-‐time inventory control. Anaesthesia & Analgesia, 91(2), 337－343 2037 Improving Safety And Quality Of Mental Health Care Units In South Brazil Dinarte A. P. Ballester1, Débora Cunha1, Fábio L. Gastal* 2 1 Superintendência Médico-‐Assistencial, Gerência de Saúde Mental, 2Superintendência Médico-‐Assistencial, Sistema de Saúde Mãe de Deus, Porto Alegre, Brazil Objectives: To describe the implementation of safety and quality activities in a network of mental health services in Porto Alegre, South Brazil, based on the World Health Organization international targets; to show the development of a Patient Safety Committee and the matrix of safety indicators adapted to mental health care. Methods: After the new Brazilian Health Authority Bill in 2013, the mental health services managed by the Sistema de Saúde Mãe de Deus, in a public-‐private partnership with the Municipality of Porto Alegre, RS, was created a local Patient Safety Committee, with the participation of professionals of five mental health teams (3 mental health centers, one emergency unit and one inpatient unit, most of them specialised in the care of alcohol and drugs related problems). Observing the care process of each mental health unit, based on the expertise of the Mãe de Deus Hospital, that is certified by ONA (Brazil) and JCI, the Committee elected a matrix of six indicators, starting by the “Risk infection reduction”. Quantitative and qualitative measures have been made to observe evolution, train the teams and improve patient care. Results: The preliminary data during the second semester of 2013, related to “risk infection reduction”, having “hand cleaning” as a marker, shows an improvement over the target of more than 60% “observed opportunities”, that are hand cleaning attitudes. Other markers have been implemented and evaluated by the Patient Safety Committee, paying attention to general health status and some specific aspects as the risk of physical constraint for patients in psychomotor agitation. Conclusion: Mental health care is an innovative area in a Brazilian context. During the last decades, the model of care had a transition from the hospital to community-‐based services. There are still huge challenges to improve safety and quality in these services, to be coherent with the principle of integrated and personalised patient care. 2065 Paediatric Clinical Practice Guidelines Audit Project Sarah Patterson1, Sarah Dalton* 1 1 Clinical Excellence Commission, Sydney, Australia Objectives: Over the last several years (New South Wales) NSW has implemented Clinical Practice Guidelines (CPG) designed to standardise care for the 12 most common emergency hospital presentations for children. In 2012 the (Clinical Excellence Commission) CEC co-‐ordinated a “snapshot” audit of compliance with 7 of these CPGs to assist local hospitals improve the care of children in Emergency Departments (ED). The objectives were to: Monitor the uptake and usage of the guidelines; Identify gaps in care provision; Identify areas for improvement; Gather feedback from local clinicians to inform ongoing development and implementation of paediatric CPGs. Methods: Data collection included retrospective medical record audits using set audit criteria and semi-‐structured interview group sessions with local clinicians. Each hospital was required to review up to 70 records of paediatric ED presentations and data entry was performed by trained audit officers. Criteria in each of the audit tools included completion of clinical observations, listed tests undertaken, senior medical review and compliance with the best practice care as outlined in the CPG. Broad consultation included meeting with paediatric clinicians from urban, regional and rural hospitals in 2012. The three themes explored in the semi-‐structured interviews were access, awareness and appropriateness of CPGs. Results: 1616 records were reviewed across 29 hospitals across NSW. The documentation of clinical observations was inconsistent; pulse and temperature was recorded in more than 90% of cases while blood pressure and pain scores were recorded less than half of the time. The child’s weight was recorded was in approximately 75% of admissions. Tests performed on patients with common emergency conditions were appropriate in most cases but less than one third of patients received blood sugar testing. It is worth noting that 21% of patients with asthma had a CXR which would not be indicated in all cases as less than 20% of cases were severe asthma. A recurrent finding in this study was a lack of documentation regarding patient care. In particular a minority of cases recorded a severity assessment of the presenting illness which is used to guide ongoing management. It is worth noting that when clinicians recognised the severity of illness engagement of senior medical staff was good, with over 80% of cases of suspected bacterial meningitis receiving senior medical review. Clinicians providing feedback included doctors (31%), nurses (65%) and management staff (4%). In general guidelines were widely accepted and there was agreement regarding their value in supporting paediatric urgent care. Clinicians reported a desire for easy access to appropriate clinical information and supported the ongoing monitoring of guidelines usage. Suggestions for improvement included ongoing development of the suite of CPGs, create a new implementation model and communication strategy and reinvigoration of CPG e-‐learning modules. Conclusion: From the analysis of the snapshot audit it can be concluded that paediatric CPGs in NSW are valued but uptake and usage are inconsistent and require further emphasis. Areas for improvement include increasing the documentation of severity assessment which may help to guide and assist busy clinicians, clinicians who are not paediatric trained and those in EDs across NSW without 24-‐hour medical cover. A particular strategy is required to encourage comprehensive clinical observations including weight and blood sugar testing in paediatric patients. Future efforts will concentrate on harmonisation of information within guidelines, alignment of guidelines with other CEC programs such as Between the Flags, the development of a communication strategy and ongoing support for local hospitals to undertake more regular snapshot audits. 2080 Using Control Charts To Monitor And Assess Improvement Of Catheter-‐Related Bloodstream Infection In Surgical Intensive Care Unit Hung Fang Ming * 1, Chen Chung Wei1, Wang Chao Ping1, Tung Chai Mei 1 1 Surgical Intensive Care Unit, Far Eastern Hospital, Taipei, Taiwan Objectives: Catheter-‐related bloodstream infection is an important cause of nosocomial infections in the intensive care unit; incur patient morbidity, mortality, extra ICU stay and medical costs. In this research, we adopted the control chart to monitor catheter-‐related bloodstream infection rate, based on Taiwan Clinical Performance Indicator (TCPI) definition, with the indicator trends data from real-‐time monitoring and causes analysis can manage the system in steady state, before exceed the upper control limit, immediate intervention to improve and reduce catheter-‐related bloodstream infection. Methods: This study follows TCPI definition to collect, and used control chart (p-‐chart) to monitor since 2009. When indicator exceed the upper control limit (UPP) or rapid rising trend, we would review and improve the abnormal reasons. For example, Catheter-‐Related Bloodstream Infection (CRBSI) in surgical intensive care unit, indicator exceed the control limit in August 2011, we reviewed literature and decided to implement the central line bundle care which developed by Institute for Health Improvement (IHI), the improvement action, includes hand hygiene, 2% chlorhexidine sterilising skin, avoid femoral vein into central line in first stage. Then, we succeed to a continually catheter-‐related bloodstream infection reduction from a set of skills of Team Resource Management (TRM), include situation monitor, remind each other in second stage. Results: According to past two year data, Indicator average 4.0‰, upper control limit (UPP) 13.2‰, low control limit (LPP) 0‰, Back to the time at August 2011 the UPP exceed to 13.8‰, then we fix it from the improvement action. We have implemented the central line bundle care in first stage, and improved the indictor average from 5.32‰ in 2011 drop to 3.69‰ in 2012. We implemented skills of team resource management simultaneously, and improved the indictor from 3.69‰ in 2012 drop to 3.21‰ in 2013, after that we adjust he standard of indicator average, and upper control limit (UPP). The standard of UPP used to setup by 13.2‰ since 2011 and now change to 12.5‰ in 2014. Conclusion: With the use of low and upper control limit in control chart to monitor indictor, an early warning of the abnormal indicator and a chance to improve it at first place. We can use control chart to monitor indicator and implement instant solution, then get improving result in daily operation .At the same time, we developed a peer hospital assessment framework base on TCPI indicator for the goal of zero infection. References: 1. Wu et. al. The Use of control chart to monitor and improve medication incident. Formosa Journal of Clinical Pharmacy 2012; 20(4):301-‐314 2081 The Improvement Of Patient Safety By Water Aerators Maintenance Maria-‐Luisa Cristina* 1, Anna Maria Spagnolo1, Fernanda Perdelli1, Paolo Orlando1 1 Department of Health Sciences, University of Genoa, Genova, Italy Objectives: Various studies have shown that tap aerators may be contaminated by gram-‐negative bacteria, including Pseudomonas Aeruginosa, Stenotrophomonas Maltophilia, Burkholderia Cepacia, and Acinetobacter Calcoaceticus. In hospital environment immunocompromised patients are particularly susceptible to infection by such microorganisms, which can cause Bacteremia, Pneumopathy, Meningitis, and other conditions. The aim of the study was to evaluate if a scheduled program of aerator maintenance could improve the microbiological quality of the hospital water and then reduce the risk of exposure for inpatients to waterborne opportunistic gram-‐negative bacteria. Methods: During 2013, we analysed the microbiological characteristics of the water supply in wards of a tertiary care hospital in northern Italy; samples of cold water were taken. We analysed the following microbiological characteristics: heterotrophic plate counts (HPCs) at 36°C and 22°C and non-‐fastidious gram-‐negative bacteria (GNB-‐NE). Cold water sampling was carried out first (time 0) with the aerators in faucets in place, to assess the risk at each outlet point. A six-‐ month scheduled program of aerator maintenance (substitution of the aerators every month) was implemented and samples of water were analysed after each aerator substitution. Results: On comparing the values of the HPCs at 22°C and 36°C and of P. aeruginosa with the target values (≤100 cfu/mL, ≤10 cfu/mL, and <1 cfu/100 mL, respectively), a 100 % of nonconformity was recorded and all samples were positive for GNB-‐NE, such as P. aeruginosa, P. fluorescens, B. cepacia, Acinetobacter spp, S. maltophilia, A. hydrophila/caviae. The mean values of HPCs at 22°C and 36°C and GNB-‐NE loads were 180.23 (cfu/mL), 67.74 (cfu /mL) and 33.15 (cfu /100 mL) respectively. After the aerators substitution the mean values for HPCs at 22°C, HPCs at 36°C and GNB-‐NE loads dropped off to 73.12 (cfu /mL), 6.23 (cfu /mL) and 0.95 (cfu /100 mL) respectively, with statistically significant differences (P <0.001). Moreover the percentage of nonconformity of samples for HPCs at 22°C, HPCs at 36°C dropped off to 32 %. No sample was positive for Pseudomonas aeruginosa and the percentage of samples positive for GNB-‐NE was 28%. Conclusion: Our results show that an adequate maintenance of aerators could improve the microbial quality of water and then reduce the risk of exposure of at-‐risk inpatients to waterborne opportunistic gram-‐negative microorganisms. Thus, given the potential healthcare risk posed by aerators, in that they can constitute a reservoir and a source of infection, there is clearly a need to place greater emphasis on the management of these devices. As has been pointed out by other authors, safe water is vital to ensuring patient safety and reducing costs in settings where waterborne infections increase morbidity, mortality, treatment costs, and compensation claims and prolong hospital stays. 2083 Enhancing Patient, Staff And Equipment Safety Through Failure Modes And Effects Analysis (FMEA) On MRI Suite Safety In JCI Accredited Tertiary Care Teaching Hospital Muhammad Akbar Khan1, Imran Ahmed1, Zafar Sajjad1, Mirza Rehanullah Baig* 1 1 Radiology, Aga Khan University Hospital, Karachi, Pakistan Objectives: The objective of this quality improvement project was to re-‐examine MRI safety protocols and their compliance with the addition of 2nd MRI through systematic approach of Failure Modes and Effect s Analysis (FMEA). Methods: An FMEA team comprising of Radiologists, MR Technicians, Administration, and Reception Staff was formed. Team began by reviewing the existing protocols pertaining to MRI Safety together with the new layout of the MRI Suite. A process-‐flow diagram was developed and the group brainstormed on all the possible failure modes from patient registration till the time when patient leaves the MRI suite. Each failure mode was then rated against probability of occurrence, level of consequence, and existing detectability to arrive at the Risk Priority Number (RPN) for each failure mode. Those with the greater RPN value were focused to develop action plans so as to improve process safety. The actions are in implementation phase which are regularly followed up for timely completion. Results: The FMEA resulted in identification of a number of improvement opportunities for ensuring MRI safety. These included: a) complete revision of MRI Safety Policy in line with the new MRI Suite layout, b) division of MRI area in four safety zones with respective access and safety requirements, c) refresher and periodic trainings of MRI personnel on MRI Safety, d) revision of patient screening form, e) revision of patient education material, f) monthly MRI safety inspections, and g) introduction of MRI safety audits on quarterly basis. Conclusion: MR areas pose a major risk to patient, staff, and equipment safety and require a continuous focus despite history of low incident rates. Continuous training and monitoring are essential to keep focus on safety precautions. 2086 A Case Study Of The Investment Cost For Patient And Healthcare Workers Safety Concerning PCI Shinji Mukai* 1, Toru Hashiguchi2 1 Suzuka General Hospital, Yamanohana Town, Suzuka City, Mie, 2Nihon Fukushi University, Mihama Town, Chita City, Aichi, Japan Objectives: In this study, firstly, from the perspective of the size of the total amount of the investment cost for consultation (Hereinafter referred to as “Consultation Cost”) and of a variety of health risks concerning the consultation (Hereinafter referred to as “Consultation Risk”), in the total hospital consultation service, especially focusing on Percutaneous Coronary Intervention (PCI) , which is one of the typical medical treatment for heart disease regarding life support, It estimated the investment cost for patient and healthcare workers safety concerning PCI. Moreover, it considered whether the total amount of the investment cost for patient and healthcare workers safety (Hereinafter referred to as “PHS Cost”) is reasonable in comparison with Consultation Risk. Methods: At first, It investigated the PHS Cost of the all hospital consultation service in 5 acute care hospitals (Beds: 499 and less) by cost accounting and was calculated the mean value concerning a ratio occupied by that PHS Cost in total hospital costs. Next, on the basis of the above mean value, by use of the survey data concerning different 2 acute care hospitals (Beds: 400-‐499), estimated the total amount of PHS Cost concerning PCI (Hereinafter referred to as “Simple Estimatio). Moreover, it weighted for each hospital consultation services with due consideration for Consultation Risk (Calculation of the coefficient for each medical department), and estimated the total amount of PHS Cost concerning PCI with due consideration for that coefficient (Hereinafter referred to as “Meta-‐Estimation”). And furthermore by the comparison between this Meta-‐Estimation and the above-‐mentioned simple estimation it analysed the divergence of the amount between both estimation, moreover, discussed about the cost for longer form of investing as PHS Cost for PCI, properly speaking. Results: The amount of PHS Cost in the above 5 hospitals mostly showed a numerical value in accordance with the scale of hospital beds. The ratio occupied by that PHS Cost in total hospital costs was approximately 1.2%. Thereafter, in the investigation concerning PHS Cost for PCI in another 2 hospitals, Average amount per a case concerning PCI was approximately 920,000 JPY (1US dollar = 100 Japanese Yen: JPY). Based on this numerical value data, when it analysed PHS Cost for PCI per 1 Year, each hospital is necessary to invest approximately 4,000,000 JPY. Conclusion: It was found the divergence of the amount between Meta-‐Estimation and simple estimation. Hereafter, along with increase the more sufficiently number of samples to be examined, instead of the data in a single year, such as this survey, it is necessary with ageing study and accumulate a long term data more reliable. References: • Brennan T.A., Leape L.L., Laird N.M., et al., Incidence of adverse events and negligence in hospitalised patients: Results of the Harvard Medical Practice StudyⅠ. N Engl J Med; 324: 370-‐377, 1991. • Leape L.L,, Brennan T.A., Laird N.M., et al., The Nature of adverse events in hospitalised patients: Results of the Harvard Medical Practice StudyⅡ. N Engl J Med; 324: 377-‐384, 1991. • Thomas E.J., Studdert D.M., Newhouse J.P., et al., costs of Medical Injuries in Utah and Colorado. Inquiry;36:255-‐ 264, 1999. 2087 Applying Innovative Cloud Technology For Ureteral Stent Implants Management Wei-‐Lun Liu* 1, 2, Chian-‐Shiung Lin3, Wen-‐Chou Fan3, Chia-‐Jung Chen1 1 Center for Quality Management, 2Intensive Care Medicine, 3Urology, Chi Mei Medical Center, Liouying, Tainan, Taiwan Objectives: Double-‐J Ureteral Stents (DJUS) are commonly used to manage urinary obstruction and negligence on the part of the patients and absence administration of a stent registry may lead to forgotten ureteral stents and their attendant complications. We designed a computerised implant management system to ensure DJUS timely removal. Methods: The implant management system was designed in the Computerised Physician Order Entry (CPOE) system. After DJUS insertion, when the physicians typed the operation notes, they could simultaneously key in the implant name, implantation site, implantation date, and the estimated removal date into the cloud-‐based implant management system (table 1). The computerised system would memorise the information and automatically search whether the DJUS removal had been done. If the removal date was overdue, and the patient had a return visit, the computer screen hint message “remove the implant” in the CPOE would appear to remind the doctor to remove the DJUS. If no return visit occurred yet, the system would automatically obtain the list of patients who received no implant removal yet and sent a message via cell phone to remind the physicians offering follow-‐up treatment. At the same time, the patient list would be sent to the patient referral center in order to contact those patients for return visits. Results: Since the cloud-‐based implant management system on-‐line and plied by 168 physicians from August 1, 2013 to January 16, 2014, the completion rate of registry was 100%. The rate of the forgotten DJUS removal was zero, and the rate of the overdue DJUS removal was 6%. Analysis of the reasons for overdue DJUS removal, all of them were because of the treatment needs or adaptation to the return visit schedules. In addition, the mean DJUS indwelling time was 46 days, which was much shorter than the estimated indwelling time, 106 days. Table 1: The Implant Management System Chart No.: Date: Division: Physician’s name: Operation code: Implants：□ Yes □ No Implant name: Implantation Date: Estimated indwelling Estimated removal date: □Permanent duration: Site □Left □ Right □ Bilateral □ Not applicable □ Anterior □ Posterior □ Superior □ Inferior □ Others Remark Conclusion: The cloud-‐based implant management system enhanced the patient-‐centered care by reminding both the physician and patient for a return visit to assure the implant timely removal. It is an innovative, cost-‐effective method to reduce forgotten ureteral stents and ensure patient safety. 2095 Adverse Events And Death Related To The Use Of The Magnetic Resonance Equipment * 1 2 Ricardo A. M. Sá , Walter Mendes 1 2 Gerência de Engenharia Clínica, Secretaria de Estado da Saúde de Goiás, Goiânia, Escola Nacional de Saúde Pública Sérgio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil Objectives: The aim of this work was identify the occurrence of Adverse Events related (AE), and the death caused by AE related to the use of the magnetic resonance equipment informed in incident notification system. Methods: The AE notifications were collected from the Manufacturer and User Facility Device Experience Database (MAUDE). The AE were classified based on Shepherd model (The Systems Risk Model -‐ SRM). The concept of AE used in this study was: "events that produce, or potentially may produce unexpected or unwanted outcomes that affect the safety of patients, users or others". The World Health Organization (WHO) recommends that health care systems should be able to identify, report and recalls all incidents, especially AE. A few authors have developed a generic system risk model to search and to analyse the root causes of AE. This system can be useful for identifying these causes and improve the protection of the health and safety of patients and users by disseminating information and to prevent the occurrence of AE. Results: We found 1487 AE related to the magnetic resonance equipment, being 12 related to death, and 774 of them were related to injury, 295 reports were related to “malfunction”, 349 reports related to “others” and 51 reports related to “No Answer Provided”. We analysed the 12 deaths occurred. Three cases were excluded because they are repeated. From the remaining 9 cases 7 were deaths of patients and 2 were deaths of professional maintenance. The causes of deaths of patients were: heart attack (3 cases), respiratory arrest due to disconnection or malfunction of the anaesthesia machine (2 cases), collision with ferromagnetic objects (1 case) and diagnostic error (1 case). The causes of deaths to maintenance professionals were asphyxia and collision with the magnet. Conclusion: We think that Shepherd model is very useful to identify causes and assess the risks of AE surveyed. There is a large number of reports of medical device-‐related AE compared to the other components (plant, operator, patient and environment), which may reflect a bias, because the Shepherd model focuses in medical devices to the detriment of other components. For future studies, we propose to use the model to evaluate the Shepherd AE related to the use of radiology equipment like conventional x-‐ray, ultrasound and mammography. References: • Mendes W, Martins M, Rozenfeld S, Travassos C. The assessment of adverse events in Brazilian hospitals. International Journal for Quality in Health Care 2009: 1-‐6. • Murff HJ, Patel VL, Hripcsak G, Bates DW. Detecting adverse events for patient safety research: a review of current methodologies. JAMIA 2003; 36:131-‐43. • ECRI. Safety Management. Health Hazard Control, Volume 1, Safety and Behaviour, Plymouth Meeting, PA, 2006. • Dyro J. Safety Program Hospital. Encyclopaedia of Medical Devices and Instrumentation. Second Edition, Ed. John G. Webster, John Wiley & Sons, Inc. 2006. • Maranhão, R. Levantamento e Análise de Eventos Adversos com Aparelhos de Tomografia Computadorizada. Dissertação apresentada com vistas à obtenção do título de Mestre Modalidade Profissional em Saúde Pública na Escola Nacional de Saúde Pública da Fundação Oswaldo Cruz. 2009. • CDRH. Ensuring the Safety of Marketed Medical Devices. CDRH’s Medical Device Post market Safety Program; January, 2006. • ACCE – Health Technology Foundation. Impact of Clinical Alarms On Patient Safety. Plymouth Meeting, PA: ACCE, 2006. • Shepherd M. A Systems Approach to Medical Device Safety, In: J. Dyro, Ed. Clinical Engineering Handbook. New York, NY: Elsevier Academic Press 2004; 246-‐249. • Sá RAM, Mendes W. Assessment of adverse events (AE) related to the use of the Computed Tomography Equipment. Abstract accepted in ISQua 2012. 2120 Quality And Patient Safety Tuesdays: Transforming An Auditing Process Into A Continuous Improvement Suzana M. Bianchini1, Marcia U. Amino2, Natal C. M. Junior2, Luciana M. Berlofi* 3 1 Practical Care Supervisor, 2institutional development, 3Gerência de Unidades de Internação -‐ Inpatients Units Manager, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil Objectives: Report the experience of the Hospital Alemão Oswaldo Cruz in implementing an internal audit process, focused on the international patient safety goals and pain management, as a tool of continuous improvement and consolidation of the institutional culture of quality and safety. Methods: A experience report of the implementation of the Quality and Patient Safety Tuesdays Program in the Hospital Alemão Oswaldo Cruz, in the city of São Paulo. Structured in a partnership between the Clinical Care area and Institutional Development area, it was formed a group of internal auditors composed by professional of health care and administrative staff, who every two weeks, has visited some units of the hospital looking for compliance with the routines and protocols related to the patient safety goals and pain management. The audits were guided by an instrument which included targets listed by internal leaders of the Joint Commission International related in the chapters of "International Patient Safety Goals" and "Care of Patients". Each item in the instrument should be signalled as fully met, partially met and missed, according to the observation of professional practice and the opportunity to interview with them. The audit starts with a brief meeting to discuss the plan of action drawn from the main finding of the previous. The next hour is dedicated to the audit process itself. At the last step every pairs of auditors present the main findings of each area audited and the entire group elects the most important finding for the development of a plan of action (PDCA). Every collected data are tabulated and compiled by "sector" and "item" and reported in the intranet for the whole institution, enabling the transparency of the program and the participation of all professionals. Results: In 2012 and 2013, ten audits contemplated, exclusively, the international patient safety goals and the pain management. There was a positive linear tendency to prediction in compliance findings during the audits, except in the "goal 4", whose elements measurement were undergone for a restructuring over audits, making them more objective. The results of a systematic audit, together with the developed and monitored action plans, supported the construction of PDCAs which were used as a tool for continuous improvement of some healthcare processes. Conclusion: The mapping and the stratification of care outcomes through audits of Quality and Patient Safety Tuesdays, proved to be an important tools for the consolidation of the institution and its professionals in a continuous process in search of quality culture and a practice care each day more secure References: 1. Padrões de Acreditação da Joint Commission International para Hospitais [edited by] Consórcio Brasileiro de Acreditação de Sistemas e Serviços de Saúde. 4ª ed. Rio de Janeiro: CBA: 2010 2. ANVISA, Ministério da Saúde. Assistência Segura: Uma Reflexão Teórica Aplicada à Prática. Série: Segurança do Paciente e Qualidade em Serviços de Saúde. 2013. 3. ANVISA, Ministério da Saúde. Boletim informativo: Segurança do paciente e qualidade em serviços de saúde. v.1(1), 2011. 2141 Development And Validation Of An Alert Mechanism That Precedes Expected Bed Exit In Hospitalised Patients Eyal Zimlichman* 1, 2, Dalia Argaman3, Rina Weizman3, Zvika Shinar3 1 Quality Management, Sheba Medical Centre, Tel-‐Aviv, Israel, 2The Centre for Patient Safety Research and Practice Division of General Medicine, Brigham & Women's Hospital and Harvard Medical School, Boston, United States, 3Earlysense ltd., Ramat-‐Gan, Israel Objectives: In this work we used a contact-‐free under-‐the-‐mattress motion sensor (EarlySense Ltd) to measure the response time to bed-‐exit alerts, and to test a novel solution to bridge this gap by predicting when a patient is about to fall or leave the bed, thus allowing sufficient time to respond. Methods: The monitoring system consists of a piezoelectric motion sensor placed under the mattress, a bedside monitor displaying heart rate, respiration rate and motion and a central display station with pagers for nurses1. Based on readings from the bedside monitor, we statistically summarised the median response time of a caregiver to a bed exit alert. We analysed over 1 million monitoring hours in 3 different sites – two general medical surgical units (sites 1 & 2) and one long term care facility (site 3). The analysis included an overall period of more than 5 years of monitoring. Based on the ability of the system to detect cardiac and respiratory motion patterns in bed, an algorithm to analyse patient signal patterns during night-‐time was developed. Using patterns that the system has learned are predictive of bed exit, a 3-‐level predictor was defined, with the 3rd level representing the highest probability for upcoming bed exit. System validation was done both retrospectively and prospectively. For retrospective analysis we ran the algorithm off-‐line on data recorded in two clinical sites (marked 1 & 3), and used retrospectively calculated bed exit detection to evaluate performance of the predictive algorithm. For prospective analysis, we tested an implementation of the algorithm in the field, during night-‐time between 23:00 till 06:00 the next morning. An observer responded to every prediction alert and documented whether it led to an actual bed exit. Results: Median Response time for bed exit alert varied from 49-‐91 seconds (see table), with site #1 representing a unit with a very strict fall-‐ prevention program. Site # 1 2 3 Hours recorded 430,420 394,946 555,514 Number of bed exits recorded 10,922 6,691 25,614 Median response time [sec] 49 77 91 th th 25 & 75 percentile response time [sec] 41 -‐ 69 57 -‐ 93 79 -‐ 113 Retrospective analysis results for bed exit prediction indicator on data from sites #1 (667 nights) and #3 (543 nights) had positive predictive values (PPV) of 37% and 39% respectively with sensitivity of 53% and 64% and average time of alert before actual bed exit of 72 and 57 seconds respectively. Since actual bed exit was considered as positive prediction. It is reasonable to assume higher PPV for patients sitting in bed. For the prospective evaluation of system implementation, we considered success of predictor level 1 or 2 if a patient was found to be awake, and for predictor level 3 if a patient was found sitting in bed (at night time). Results showed PPV of 38%, 56% and 67% for indicator levels 1, 2, and 3 respectively. I.e. in 2 out of 3 events of indicator level 3, the patient was sitting in bed instead of lying down during night time. Conclusion: We have found a lag of approximately 50-‐90 seconds between the bed exit alarm and the staff’s response. An algorithm developed to predict fall/bed exit was found to precede the event by 57-‐72 seconds and with a positive predictive value of up to 67%. Being able to predict ahead of time patient falls or bed exit will allow the staff to provide timely assistance at the bed side and potentially prevent the fall. Further research will need to examine this possibility in an interventional controlled clinical trial. References: Ben-‐Ari J, Zimlichman E, Adi N, Sorkine P. Contactless respiratory and heart rate monitoring: validation of an innovative tool; J Med Eng Technol. 2010 Oct-‐Nov;34(7-‐8):393-‐8 Disclosure of Interest: E. Zimlichman: None Declared, D. Argaman Employee of: EarlySense ltd, R. Weizman Employee of: EarlySense ltd, Z. Shinar Employee of: EarlySense ltd 2149 Reducing The Irrational Use Of Therapeutic Antibiotic In Elective Caesarean Section Nigar Jabeen* 1, Raheel Gujrati2, Ambreen Memon2, Sana Zahiruddin1 1 OBGYN, 2Administration, The Aga Khan Maternal and Child Care Centre, Hyderabad, Hyderabad, Pakistan Objectives: To minimise irrational use of antibiotics by 50% in first half of 2013 as compared in 2012, in full time faculty cases by implementing the standard guidelines for antibiotic usage in elective caesarean section. Methods: Data was collected from medical records on a prescribed Performa. Data on demographics, type of surgery, timing and dose of antibiotics, duration of surgery, complications on intraoperative and post-‐operative findings. Our dashboard indicator recorded in 2012 indicated that therapeutic antibiotic rate is increasing with subsequent quarters from 96% to 99% whereas actual bench mark is less than 30%.By Using the PDCA (Plan-‐Do-‐Check-‐Act) methodology along with brain storming sessions and by implementing number of improving strategies: To give bath prior to surgery, Effective hand-‐ washing and scrubbing techniques, Avoid the mobilisation of staff/doctors once they enter the operating room, Ensure the proper cleaning and sterilisation of the operating room before and after any surgery, Ensure the proper process of sterilisation of instruments/materials used in surgery, Giving sponge and bath on 1st and 2nd post-‐operative day, Awareness Sessions conducted for physicians and nursing staff, Available 1st generation antibiotics in pharmacy, Strengthen operating room booking process. Results: 52% reduction in use of irrational antibiotics recorded till 2nd QTR 2013 as compared with year 2012. Conclusion: By reducing irrational use of antibiotics following achievements were noticed: ! 53% reduction in cost paid for antibiotics to patient. ! Probability of drug interactions decreased. ! Risk of Side effects decreased. ! Chances of bacterial resistance decreased. ! Reduction in wastages of resources, ultimately impact of economic condition of region. 2192 An Evaluation Of A Complex Social Intervention To Build High Reliability Patient Care Teams 1 * 1 2 3 Robyn Clay-‐Williams , Julie Johnson , Peter Kennedy , Gabriel Shannon 1 2 3 Australian Institute of Health Innovation, University of New South Wales, Clinical Excellence Commission, Sydney, Orange Health Service, Western New South Wales Local Health District, NSW Department of Health, Orange, Australia Objectives: There has been a decline in public confidence in the safety and reliability of healthcare. Patients cite lack of teamwork as one reason for poor satisfaction with inpatient care. In Safe Hands (ISH) is a team-‐based, patient centred model of care developed by the Clinical Excellence Commission (CEC) to improve performance of teams on the inpatient ward. ISH requires comprehensive changes to the ward’s culture, work practices, and team functioning. Redesigning ward rounds is at the heart of ISH, in which medical, nursing, and allied health staff conduct a bedside round at approximately the same time daily to seek input from the patient/family, and set a daily plan and goals for the patient. The aim of ISH is to replicate high-‐reliability patient care teams and to deliver excellent care as standard to all patients across the NSW public health system. Orange Health Service (OHS) was the first hospital to implement ISH in NSW, with rollout staged for 21 sites across the state. For ISH to be successful, it must be acceptable to those responsible for putting it into operation – the healthcare professional teams at the front line microsystems of care. Identifying the challenges and successes from the pilot ISH intervention can guide future implementation at hospitals across NSW. We conducted an evaluation of implementation of ISH at OHS to: 1. 2. assess the impact of the ISH program on team functioning, staff experience and job satisfaction; and identify lessons learned from the proves of implementing ISH. Methods: Qualitative evaluation methods included observation of ward rounds and semi-‐structured interviews with the leadership team responsible for the implementation of ISH and the front line clinical staff (doctors, nurses, allied health, managers and ancillary staff) whose daily work was directly affected by the redesign. A modified form of the ‘constant comparative method’ was used to achieve thematic analysis of the interview transcripts. Results: Three researchers conducted observations and interviewed 32 participants. Five main themes emerged from the inductive analysis: (1) (2) (3) (4) (5) strong impact of culture on the implementation and ongoing operation of the ward, the importance of leadership to guide the changes, changes to workflow required with the new care model, benefits of the new model of care for clinicians, staff, and patients, and challenges associated with the implementation process. Results were further categorised into (1) improvement recommendations for the local ward and (2) recommendations for wards planning implementation. Conclusion: Complex social interventions, such as the ISH initiative, require evaluation as an important component of implementation and improvement strategies. Typical methods of collecting and reporting quantitative results do not tell the whole story, which leads to a lack of appreciation for the “whole system” changes that are needed to support the work. The context of the intervention site has important implications for the effectiveness of the implementation process. Recommended practices for successful implementation are to: 1. 2. 3. 4. 5. prioritise an early stakeholder communications and management strategy to fully inform and engage all those affected by the new model of care about planning and implementation develop and provide orientation and training provide ongoing mentoring and make necessary mid-‐course adjustments put the patient at the centre of all care processes, and build evaluation into the intervention rollout. 2193 Developments Of Culture Of Patient Safety: Comparative And Linear Analysis With Americans Hospitals Elenara O. Ribas* 1, Michele S. Malta1, Fabio L. Gastal2, Luiz Felipe S. Gonçalves3 1 Epidemiology Service and Risk Management, 2Mãe de Deus Hospital, Porto Alegre, Brazil, 3Medical Board, Mãe de Deus Hospital, Porto Alegre, Brazil Objectives: The safety culture is the commitment the all organisation with promotion continues a safe environment. Implementation of programs appraisal and continuous improvement are suggested the National Quality Forum a Joint Commission International for evaluate the safety culture. The organisation in this study establishes actions since 2006 for improved safety and one interests is measure if this actions are established are effective perception of professional. Agency for Research and Quality (AHRQ) propose the survey for measure the perception of professional, this Hospital Survey Safety Culture and the organisation in this study uses this method to measure safety culture, analyse evolution the safety culture in one organisation and compare with the Hospitals Americans. Methods: Descriptive study and quantitative analysis. The Hospital Survey Safety Culture was translated and subjected to professional the periods 2008, 2010 e 2012. Was used twelve fields of research – communication openness, feedback and communication about error, frequency of events reported, handoffs and transitions, management support for patient safety, non-‐punitive response to error, organisational learning–continuous improvement, overall perceptions of patient safety, staffing, supervisor/manager expectations and actions promoting safety, teamwork across units. This answer was individual, the choice in each option, was for positively worded strongly agree, or agree, or always, or most of the time and for negatively worded strongly disagree, or disagree, or never, or rarely. The results were reviews proposition AHRQ. Was compare 2008, 2010 and 2012 for chi-‐square test for linear trend and for comparison with American Hospitals, AHRQ’s suggestion was used, compared organisation with the same number of beds, compared HMD 2012 and AHRQ 2011, for chi-‐square with Yates correction with 5% significance. Results: Observed a positive linear trend , over the four years in institution for four groups relative to teamwork within units, supervisor/manager expectations and actions promoting safety, management support for patient safety, organisational learning–continuous improvement, overall perceptions of patient safety, feedback and communication about error, communication openness and frequency of events reported, p<0,001, however in group associated handoffs and transitions, non-‐punitive response to error no significant difference. When compared to data from AHRQ, this organisation, submitted organisational learning–continuous improvement, feedback and communication about error, frequency of events reported more than AHRQ p <0,001, the issues teamwork within units, supervisor/manager expectations and actions promoting safety, teamwork across units, non-‐punitive response to error and staffing, this organisation get numbers smaller AHRQ p<0,001.The other groups not present statistical significance. Conclusion: Observed the actions for safety culture, had a significant growth over time; however there are still opportunities for improvement related the staff, teamwork within units, for attained international standards in quality and safety. References: ! Patient Safety Culture Surveys Agency for Healthcare Research and Quality, in: http://www.ahrq.gov/qual/hospculture Institute for Healthcare Improvement, in www.ihi.org. ! Join Commission International. Hospital National Patient Safety Goals. Provonost, P.J; Colantuoni, E. Measuring preventable harm: helping science keep pace with policy. JAMA, Mar 2009. 2195 Introduction To Prospective Analysis Of Patient Safety By Risk Audits Daniela A. Costa* 1 1 Quality & Safety, Hospital Sao Camilo, Sao Paulo, Brazil Objectives: Verify adherence to protective barriers imposed on prevention protocols through audit risk, comparing the performance between the years 2012 and 2013. Methods: Using specific tools based on preventive measures devised protocols to avoid or reduce adverse events, Risk Audits were structured in three phases: 1) 2) 3) Review of patient records, Analysis on the environment and Approach to the Patient / Family are performed from a cross sectional sample of 20% of the number of patients at risk of fall, pressure ulcer, phlebitis and pulmonary aspiration. The overall results were presented to teams where improvement actions such as training and daily review of the measures were stablished. Results: In 2012 were performed 331 audits and in 2013 were effected 432. Compared to the Canadian Patient Safety Institute report from 2010, in which compliance rates for preventing falls and pressure ulcers were 69% and 89%, respectively, we obtained similar rates of compliance in 2012 and 2013, with 66% and 73% for fall, and 86% and 84% for pressure ulcers. The compliance rate for aspiration and phlebitis were 62% and 66% in 2012, and 62% and 71% in 2013. When analysed separately compliance rate for preventative measure we can find some critical points, below 50%. Protocols Aspiration Fall Ulcer Pressure Phlebitis Preventive Measures Daily assessment of patients with impaired swallowing Daily measuring of cuff pressure of patients with tracheal cannula Prescription of diet adapted by speech therapist Educational plan for patients -‐ medical record Preventive measures prescribed by nurses Bell within reach of patients Evidência de mudança de decúbito de 2/2 horas Skin hydration Identification of the risk Assessment of venous to select the type of intravenous catheter 2012 (%N) 36% 39% 50% 39% 48% 55% 32% 47% 30% 29% 109 111 56 52 2013(%N) 75% 89% 81% 42% 83% 100% 53% 72% 86% 43% 127 116 99 90 We identified that there was a slight improvement from the overall results from 2012 to 2013. Regarding the risk of aspiration, improvement occurred in the differentiation of micro and macro aspiration and evaluation process that came to be in multi-‐visit because earlier assessment was given from imaging tests. In the case of phlebitis, a simple change of risk assessment which before it was taken only at admission, has become daily and increased the sensitivity and speed in detecting signs of inflammation. However there are still opportunities for improvement in choosing the best type of catheter. For falls, the improvement occurred in the prescription of preventive actions by nurses and the disposition of bells near patients, however, there are opportunities to improve communication with patients, aiming to engage them in the adoption of preventive measures such as use of footwear appropriate and call nurses when they need go to the toilet. For patients at risk for pressure ulcers, products skin hydration and skin protection were replaced by others of better quality, but the position change is still a challenge for the team. Conclusion: We understand that the prospective analysis of safety through risk audit is an important tool for evaluation of preventive measures and serve as an educational process when we observe inconsistencies, promoting the immediate adaptation of care actions and contributing to reduction of adverse events. As a future study is intended to include patients in improvement actions from their own experience. References: Canadian Patient Safety Institute – Report 2010 2217 Use Of Team Resource Management Technique To Improve Extra-‐Corporeal Membrane Oxygenation Care Quality Hung Yu Liu* 1, Mei Fang Cheng1 1 Nursing, Cardiovascular Intensive Care Unit, Far Eastern Hospital, New Taipei City, Taiwan Objectives: Extra-‐Corporeal Membrane Oxygenation (ECMO), a kind of high technical and promoting care therapeutic way, can provide patients for waiting recovery of heart function, bridge of heart transplantation, and resting time of lung. Care of patients with ECMO is a tough and complicated task, and needs a group of professional cooperative technicians (including physicians, nurses, cardiopulmonary bypass professionals, ECMO technicians, respiratory therapists, dieticians, pharmacist, and social workers). In 2013, the event of abnormal connective piping of ECMO system was happened in our unit, and leaded to patient’s irreversible damage. Thus, it suggests that combination with team resource management proceeds the case investigative amelioration to avoid damage happening again. Methods: 1. Modulating collaborative relationship between nurses and physicians forms multidisciplinary ECMO care team. 2. Standardising nursing care with the procedure (multiple disciplines). 3. Training and evaluating in advance the nursing staffs (seniority over two years), and they can take care the patients with ECOM after verification. 4. Arranging regular ECMO continuing education and care skill manoeuvre. 5. Recording the ECMO check list together with every multidisciplinary nurses and physician’s team. 6. Discussing each ECMO case situation of every multidisciplinary nurses and physicians team every week. 7. Maintaining routine quality control management and ECMO care skill surveillance.8.Proceeding ECMO exception handling process manoeuvre. Results: In 2013, after care precautions had been intervening in, nursing evaluation: (1) Abnormal ECMO incident event decreases from one to zero. (2) The value of quality control management EAMO care skill achieves 100 percentage. Conclusion: ECMO Adjuvant therapy needs a group of experienced team (members including physicians, nurses, cardiopulmonary bypass professionals and so on) to participate in care of patients. Using intervening care precautions with team resource management technique may provide total life support for patients; find the complication or abnormality in advance. It also can diminish risk to minimum by urgent handling, decrease the medical cost, effectively promote excellent quality of intensive care, and together maintain the patient safety. 2222 Global Trigger Tool: An Approach To Enhance Patients’ Safety * 1 2 Gulzar S. Lakhani , Aqsa R. Sajwani 1 2 Clinical Affairs, Chief Operating Officer Office, Aga Khan University Hospital, Karachi, Pakistan Objectives: The Aga Khan University Hospital (AKUH) believes in quality and patient safety. The mission of providing exemplary care to patients can only be achieved by creating a harm free environment. AKUH has taken an initiative by adapting IHI’s (Institute of Healthcare Improvement) global trigger tool (GTT) for identification and reduction of medical harms. The purpose of using IHI’s GTT was to identify the number of adverse events in hospital, categorise them according to severity of harm, establish strategies to reduce harm rate and compare with our own trends to improve it over time. Methods: A cross-‐sectional retrospective review was done from January 2011 to December 2013 using standard IHI’s GTT. A random sample of 20 closed medical records were reviewed per month and audited first by a patient safety nurse, then by a clinician, against ‘53’ triggers mentioned in the GTT. Complete medical records of adult, non-‐psychiatric patients, who were shifted to high dependency area during the hospital stay, were selected. The data was then classified according to the severity of adverse events (E, F, G, H and I). Identified adverse event were shared with the senior leadership and department heads of the organisation. Furthermore, an action plan on the identified areas of improvement was developed and implemented on unit level to bring improvement in the processes. Results: Medical record reviews of 720 were performed in three consecutive years from 2011 to 2013, in which a total of 208 adverse events were identified which were categorised as per the severity of adverse events. About 147 (70.67%) adverse events contributed to temporary harm to patient requiring intervention (Category E), while 47 (22.59%) required prolonged hospitalisation (Category F), 04 (1.92%) lead to permanent harm (Category G), about 07 (3.36%) required intervention to sustain life (Category H) and 03 (1.44%) led to patient’s death (Category I). Following table 1 will provide year wise calculation of adverse events. Table 1: Harm categories Category E: Contributed to temporary harm to the patient and required intervention Category F: Contributed to temporary harm to the patient and required initial/prolonged hospitalisation Category G: Contributed to permanent patient harm Category H: Required intervention to sustain life Category I: Contributed to the patient’s death Cumulative 2011 66.60% (64) 22.90% (22) 4.10% (4) 5.20% (5) 1% (1) 2012 78.40% (58) 17.40% (13) 0% 2.70% (2) 1.40% (1) Year 2013 65.78% (25) 31.57% (12) 0% 0% 2.63% (1) 208 Cumulative 70.67% (147) 22.59% (47) 1.92% (4) 3.36% (7) 1.44% (3) Based on the data analysis, the following areas of improvement were identified and action plan was developed and implemented for each of these areas. ! ! ! ! Prevention and care of pressure ulcers and bruises Reducing nosocomial infections Reducing Incidents/Harm related to Hypoglycaemia Developing and implementing Thromboprophylaxis clinical practice guidelines Conclusion: These results suggest that adverse events are definitive source of harm to the patient. Data highlighted that by adopting this tool and working on the identified areas of improvement, the number of adverse events has decreased periodically. Global trigger tool has aided to identify those events which were not voluntarily reported. Hence, the hospital plans to continue using this promising tool to identify adverse events proactively and work accordingly to bring improvement in the processes in order to provide harm free environment for the patients. 2230 Governing Correct Surgical Count Through ViGO (Visual Gauze Organiser) Suriati Deraman1, Tan Mei Li2, Sharifah Azura Saiyed Abdul karim2, Yoong Fook Ngian* 1 1 Quality, 2Nursing, Kuantan Specialist Hospital, Kuantan, Malaysia Objectives: Ensures correct gauze count during surgery to ensure patient safety. Methods: By using simple preventive tool like ViGO in gauze counting, we recovered unremarkable method to prevent retained gauzes following surgery; which is used by team members to focus on patient safety and procedural accuracies. To embark on the ViGO counting method the management has decided to give a trial period of 6 months from August 2008 to evaluate the effectiveness and efficiency of the counting process by using ViGO. Results: The project’s short-‐term and long-‐term qualitative and quantitative result. We have successfully implemented ViGO and it has been used throughout since year 2009. A study consists of 430 cases have been analysed and found that by using ViGO, we are able to achieve zero error in missing gauze count. This visual tool has assisted the peri-‐operative team to perform gauze counting process accurately in order to prevent event of retained gauze in patient during surgery. Besides that, ViGO has shortened the counting time from 1 min to 10 seconds because the need of repetitive counting is reduced. Time available can be used to focus on counting instrument instead so that the peri-‐operative team is not rushed during the whole counting process because rushing disrupts the staff focus on patient safety. Conclusion: Patient safety has become a growing concern in KPJ Healthcare hospital. The safety of its patients is of paramount importance and KPJ believes in building a culture of safety by continuously reviewing and improving all aspect of care that directly affect safety and risk to patients. Considered totally preventable, cases of retained gauze are partly the result of miscommunication during the counting process. Having a more systematic approach of gauze counting procedure; using ViGO has indeed restore the confidence of the perioperative team to enhance patient safety; which ultimately uphold the organisation reputation as an organisation with a culture of safety, On the other hand, it will also prevent the organisation from bearing the cost and consequence of event in terms of morbidity and mortality resulted from incident of retained gauzes. References: Kaiser, C., Friedman, S., Spurling, K., Slowick, T. & Kaiser, H. (1996). The retained surgical sponge. Annals of Surgery, 244, 79-‐84. 2286 Reducing Hazards Through Handover: A Central London Teaching Hospital Experience Elinor Warner1, Catherine Ingram2, Mark Kinirons3, Adrian Hopper* 4 1 Colorectal Surgery , Guy's and St. Thomas' Hospital, 2Clinical Governance, 3General Medicine and Trust Patient Safety Lead, 4General Medicine and Trust Patient Safety Lead, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom Objectives: Despite being named “Trust of the Year” for London in the recent National “Dr Foster” report. 36% of doctors surveyed at Guy’s and St. Thomas’ Hospital had personally witnessed a patient safety incident due to the current handover system. This has led to a trust wide focus on re-‐designing end of shift handover processes, in order to facilitate the delivery of safer, better care. The overall aim was to ensure that 100% of unwell patients were handed over electronically and face to face as per clinical appropriateness. By doing so we aimed to decrease the number of patient safety incidents due to the current handover processes, develop an electronic handover tool and education training package to facilitate an improvement in the structure and quality of information handed over, as well as delivering an enhanced patient experience of handover of clinical information at our trust. Methods: An online survey identified the key issues with handover in the trust. Monthly handover improvement meetings chaired by the Consultant patient safety lead, involving all identified stakeholders, with project management support from governance allowed a clear timeline of progress. IT solutions for handover were sought, focusing on developing the existing electronic patient record for this purpose, and consultations with key experts in the field allowed the development of a rigorous structure and processes for re-‐designing handover within GSTT. Results: Questionnaire results showed that the main issues with the current system included lack of structure and leadership at handover with half the doctors surveyed feeding that handover was not well organised, interruptions from bleeps, and poor quality of information being handed. Although over 80% of doctors surveyed had a set time and place for handover the problems with handover itself frequently led to delayed assessment and investigation, diagnosis and treatment of unwell patients. Conclusion: In conclusion, the group are taking a three-‐arm approach to quality improvement. To reduce delays in assessment and diagnosis by developing the existing Electronic Patient Record system to help capture, triage and structure the handover of unwell patients. By standardising the handover information and delivery using SBAR tool, to facilitate both verbal and electronic handover. To improve team work by developing an education and training package utilising existing Human Factors and Simulation expertise. 2327 A Simple Solution To The Problems Encountered During Junior Doctor Change-‐Overs In The NHS, UK Angela Pathiraja* 1, Roaa Al-‐bedaery1, Mohsin Salahuddin1 1 Imperial College Healthcare NHS Trusts, London, United Kingdom Objectives: The junior doctor change-‐over period in the NHS is a dangerous time1: it is notoriously fraught with practical risks which instil fear in our patients, make headline news2, and ultimately compromise care and patient safety. Our group aimed to come up with a simple solution to this nationwide problem, by implementing and assessing the usefulness of a junior doctor changeover handbook -‐ "Foundation survival guide" -‐ at our busy district general hospital in London. Methods: A foundation survival guide had previously been instituted within our trust. However, its implementation and uptake had been poor, and had left our newly-‐qualified foundation year 1 (FY1) doctors feeling under-‐prepared. We used a teaching session a fortnight before the FY1 doctors' first change-‐over (in December 2013) to use a 10 point Likert-‐scale questionnaire to assess how informed and well-‐equipped they felt about starting their next job. We then used the subsequent week's teaching session to get each group of FY1 doctors on a particular firm to write an up-‐to-‐date account of their specific job descriptions. These updated job descriptions were then collated to make an up-‐to-‐date guide which was then distributed prior to change-‐over both physically and virtually (via email .pdf). The same Likert-‐scale questionnaire was then redistributed to all the FY1 doctors in order to reassess how prepared they now felt, following implementation and access to our new tool. Results: (In order to keep the abstract succinct, the results have been globally discussed below, and the raw data will be presented and available at the conference itself) The results of the 16 10-‐point Likert scale questions from 23 pre-‐ and 14-‐post-‐implementation questionnaires were collected. The questions covered 16 separate domains relating to their next job. There was a unanimous increase in Likert-‐scale scores post-‐implementation in all 16 domains, reflecting an increase in the FY1 doctors' confidence following implementation of the "Foundation Survival Guide". An additional 2 YES/No questions relating to how aware and useful they felt such aids were indicated that the majority of FY1 doctors had not previously been aware of the old handbook. However, following implementation of our tool, there was 100% awareness and agreement of its beneficial use to their practice. Conclusion: It is evident from our study that if a tool is easily-‐producible, practically relevant, and subsequently implemented effectively, something as simple as a "Foundation Survival Guide" can effectively facilitate the safe transition of our junior doctors throughout their first year as a practising doctor. With the UK's department of health endorsing compulsory shadowing of FY1 doctors prior to starting clinical practice in August, and NHS employers urging their trusts to plan their workload and staffing to reflect the dangerously high mortality rates associated with the "Black Wednesday" in August each year3, it is of paramount importance that this situation is addressed. At our hospital we plan to continue improving our "Foundation survival guide" prior to each change-‐over in order to continue to support and empower our FY1 doctors in a simple but effective way. References: ! 1 Vaughan L, McAlister G, Bell D. (2011) "August is always a nightmare": results of the Royal College of Physicians of Edinburgh and Society of Acute Medicine August transition survey. Clinical Medicine (11) 4: 322-‐326 ! 2 http://www.independent.co.uk/life-‐style/health-‐and-‐families/health-‐news/junior-‐doctors-‐your-‐life-‐in-‐their-‐newly-‐ qualified-‐hands-‐8772718.html ! 3http://www.hsj.co.uk/news/trusts-‐urged-‐to-‐reduce-‐elective-‐activity-‐during-‐junior-‐doctor-‐transition/5060526.article 2333 Consensus Of Items And Quantities Of Clinical Equipment Required To Deal With A Mass Casualties Big Bang Incident: A National Delphi Study Edward Duncan* 1, Keith Colver2, Purva Abhyanker 1, Nadine Dougall1 1 NMAHP-‐RU, University of Stirling, Stirling, 2Scottish Ambulance Service, Edinburgh, United Kingdom Objectives: Major short-‐notice or sudden impact (known as big bang [1]) incidents which result in a large number of casualties are, fortunately, rare events. However health services, including ambulance services, must be prepared. Having the right type and quantity of clinical equipment is essential, but planning for such emergencies is challenging. To date, this equipment has evolved without an explicit evidence-‐base [2]. This study aimed to develop an expert consensus opinion of the items and quantities of clinical equipment required for 100 casualties at a mass casualty’s incident. Methods: A three round modified Delphi study [3,4 ]using a be-‐spoke web-‐based platform. Participants had clinical experience of pre-‐hospital response to a mass casualty’s incident, or responsibility, or were in a position of authority in health emergency planning. Items importance were measured on a 5 point Likert scale. Consensus was deemed to have been achieved when at least 80% of respondents rated an item as unimportant/very unimportant or important/very important. Quantities of items required were measured numerically. Data were analysed using nonparametric statistics. Results: Thirty-‐two experts achieved consensus (>=80%) on a total of 134 items (54%) on completion of the study. There was considerable variation in the percentage of items that gained consensus within the subsets that had been split according to each item’s purpose (e.g. control of infection, splintage, medication). Consensus was not reached on 114 (46%) items. Median quantities and interquartile ranges of each item were identified and will be reported. Conclusion: An expert panel of individuals reached a consensus that 134 items of clinical equipment were either important or very important in response to a big bang mass casualty’s event. A further 30 items neared the agreed 80% consensus level. Indicative quantities for each item were provided. These findings provide an important resource for the UK and countries with similar response mechanisms and planning assumptions, in the planning of future emergency responses to big-‐bang mass casualty’s events. References: 1. NHS Scotland Resilience Team at Scottish Government: Mass Casualties Incidents A Framework for Planning NHS Scotland. Scottish Government; 2009. 2. Timble J, Ringel J, Fox S, Pillemer F, Waxman D, Moore M, Hansen C, Knebel A, Ricciardi R, Kellermann A: Systematic review of strategies to manage and allocate scarce resources during mass casualty events. Annals of Emergency Medicine 2013, 61:677–689. 3. Linstone HA, Turoff M: The Delphi method: Techniques and applications. Techno-‐metrics 2002, 18:363. 4. Mead D, Mosely L: The use of Delphi as a research approach. Nurse Researcher 2001, 8:4–37. 2345 Critical Missed Doses: Education And Audit Package Linda V. Graudins* 1, Catherine Ingram2, Melita Van de Vreede3 1 Pharmacy, Alfred Health, Melbourne, Australia, 2Clinical Governance, Guy's and St Thomas NHS Foundation Trust, London, United Kingdom, 3Pharmacy, Eastern Health, Melbourne, Australia Objectives: To develop a medication safety package, consisting of an audit tool, user guide and educational module, to reduce missed doses of time critical medications, therefore decreasing incidents and patient harm in hospitalised patients. Methods: Project steering committee members (nursing and pharmacy) reviewed existing tools and published studies to develop a critical medication list and audit tool. The tool, definitions and instructions were tested in rural, urban and teaching hospitals in one Australian state. Qualitative feedback was sought to refine the tool using the Plan-‐Do-‐Study-‐Act model. Audit data was collected by and collated information fed back to participating hospitals. An educational presentation was developed based on lessons from actual incidents. Results: The audit tool, user guide and list of critical medications were developed over seven months and four audit cycles. Nursing and pharmacy staff in eleven hospitals audited 17, 361 doses of medication for 321 patients. There were 749 (4.3% total) preventable missed doses. There were 116 doses missed because the medication was “not available” (range 0.3 to 4.3% across hospitals) and 633 doses missed due to “unclear documentation” (range 0.5 to 9.2%). The 45 doses involving ‘critical’ medications did not result in negative outcomes in patients audited. The educational material consists of a User Guide plus an adult learning module consisting of six cases, national recommendations for documentation of dose administration and medication safety solutions. Feedback indicated audit data was useful for improving practice and materials are now being used in several hospitals. Conclusion: The Critical Missed Doses package was successfully tested across the state and is being used by nursing and pharmacy staff. The package is available to all TAG hospitals. An electronic version will facilitate audits and encourage implementation into hospital medication safety programs. References: Reducing harm from omitted and delayed medicines in hospital. UK NPSA 2010. *This project was funded by the Victorian Therapeutics Assessment Group (VicTAG) 2352 Development Of An Incentive Program, Focused On Adverse Events Prevention And Strengthening Of Patient Safety In México Odet Sarabia* 1 1 Quality and Planning Direction, National Institute of Medical Sciences and Nutrition Salvador Zubiran, Mexico, Mexico Objectives: To find a patient safety indicator in a hospital study, relating it to an Incentive System (IS) based on the preferences of the target population that will improve patient safety. Methods: A horizontal study in which an initial determination of the perception of patient safety climate by hospital personnel is made. An evaluation of the preferences to incentivise the healthcare personnel to improve quality and patient safety is also made. This is followed by an intervention previous to the final evaluation of the patient safety climate. The actors were healthcare professionals related with supervision of training medical personnel in a third level public general hospital in Mexico City with 289 beds. The sample consisted of 500 healthcare professionals related with teaching areas: medics, nurses, technicians, undergraduate interns, and residents. 500 questionnaires on safety climate and 500 on preference evaluation to incentivise healthcare personnel to improve quality and patient safety were distributed. From these we received an initial response of 391 answered questionnaires and 429 of the final evaluation. After the intervention, the same number of questionnaires were distributed, obtaining a better response. Based on the results of the incentives questionnaire, an incentive system was designed, related to the supervision indicator of medical personnel in three levels: Hospital unit, service, and healthcare professional. Results: An increase of the number of supervised medical procedures made by training personnel was achieved, as well as an increase in the perception of a good patient safety climate. Conclusion: An incentive related to a best practice indicator can contribute to the improvement of the patient safety climate perception, as well as to the improvement of the indicator. It is noteworthy that in relation to the question of the degree of patient safety in their service, the average is lower when included in staff (p 0.11) formation in the first sample, however, no difference was observed in the second sample still with trainees, so the probability that the interpretation of this staff are supervised when in their procedures improves the quality and safety of patients is a possibility to study. It is recommended that an ongoing monitoring of staff training as a means of improving the safety of patients , continued use of blogs to embed the actions of patient safety in medical and surgical procedures performed by medical staff in training both by teachers and students , making measurements every 6 months for a long period to evaluate a trend. Being a de novo study worth exploring in another study if monitoring trainees decreases the prevalence of adverse events and complications during procedures performed by medical personnel in training. If a good indicator linked to patient safety practices as described in the study appears to be a good choice to assist in improving quality and patient safety. Promote the supervision of medical staff in training has great value to increase perceptions of interns and residents about the safety climate in their hospital unit, and most likely to avoid the presence of adverse events and complications during procedures. It's a fact that everyday life in hospitals and how to teach future doctors is changing, there will come a day that will be history when patient safety was not taken into account as a priority in health care and what why not? That health systems are as safe as air or nuclear industry; it is a matter of time. 2384 Team Resource Management Improves Safety Of Transfer Of Post-‐Surgical Critical Patients To Intensive Care Units Yu-‐Yun Wu* 1, Jun Yi Li2 1 Operating Room, 2Cardiovascular Surgery, Mackay Memorial Hospital, Taipei, Taiwan Objectives: Transfer of post-‐surgical critical patients from operation room to intensive care unit carries high risk of unexpected events and requires cooperation between surgeons, nurses and anaesthesiologists. We constructed a transfer protocol using the team resource management model to improve post-‐surgical critical patient transfer and multidisciplinary team co-‐operation. Methods: Since March 2012, a change team was formed in our operation room and intensive care unit to make sure the accuracy of conducting patient transfer protocol to improve patient safety. We investigated the most frequently encountered problems regarding to transfer of post-‐surgical critical patients to intensive care unit using questionnaire and assessment form. After confirmation of the main problems, we used team discussion and matrix analysis to improve multidisciplinary cooperation. Practicing team resource management with emphasising on the leadership, situation monitoring and mutual support domains was decided. In May 2012, we constructed a structured critical patient transfer protocol, including obligation of team leader, duty and position of team member, and two checkpoints in order to facilitate the mutual support and safety during patient transfer. Call-‐out was encouraged if any suspected risky situation was found. As a team leader, surgeon is asked to call timeout at the checkpoints to make sure all team members were ready. All team members had checklists to confirm well preparation for patient transfer. Other tools such as two-‐challenge and cross monitoring were encouraged. We took a demonstration video and used simulation to facilitate cooperation between team members and education of new staffs. Questionnaires concerning staff perception of the quality and consistency of handover, teamwork climate, and patient safety cognition were used before and 3 months after the change. Incompliant to protocol and adverse events including changes in vital signs, line dislodgement related to patient transfer were recorded. The data were analysed using chi-‐square test for dichotomous variables and t test for continuous variables. Results: The use of transfer protocol did not cause much inconvenience to all fields of professionals and was rapidly incorporated into their daily activity. Before conducting the transfer protocol, we investigated the completeness and safety in transfer of 43 consecutive post-‐surgical critical patients. Only 73.7% of the patients were transferred without missing any preparation. One patient (2.3%) had line dislodgment. Three patients (7.0%) were noted to have changes of blood pressure or heart rate more than 20%. Three months after the execution of the protocol, the completeness of transfer preparation and compliance to protocol increased from 73.7% to 99.1%. The perception of teamwork climate and the patient safety cognition increased from 55.3% to 74.5%. No marked change of vital signs, line or tube dislodgement was recorded in relation to transfer. Conclusion: Implementation of team resource management and use of structured transfer protocol improves the cooperation between multidisciplinary team member and safety of post-‐surgical critical patient during transfer from operation room to intensive care unit. References: 1. Bambi, S., & Day, D. (2010). The risk of intra-‐hospital transport to patients. "Keeping patients safe during intra-‐hospital transport" (August 2010:18-‐32 ). Critical Care Nurse, 30(6), 14-‐16. doi: 10.4037/ccn2010483 2. Day, D. (2010). Keeping patients safe during intra-‐hospital transport. Critical Care Nurse, 30(4), 18. doi: 10.4037/ccn2010446 2385 The Ins And Outs Of Paediatric CVAD's Gabrielle O'Grady* 1, Margaret Allen2, Adam Bennett2, Kay Babalis2 1 The Children's Hospital at Westmead, Sydney, 2The Children's Hospital at Westmead, Westmead, Australia Objectives: To develop an electronic tool that captures inpatient and outpatient central line days Methods: In 2010 NSW Health developed a Central Venous Access Device (CVAD )insertion and removal form. It quickly became apparent that the form was not ideal for the patients at the Children’s Hospital at Westmead. It was evident that it would be difficult to use if the patient was discharged with the line insitu. A working party was formed, inclusive of medical and nursing staff, Clinical Governance and Information Technology staff. Discussions were held to determine the most suitable options; a decision was made to develop an electronic system. It was agreed the system would need to: ! Provide documentation of CVAD insertion details, including type, site, location, insertion date, procedure list, if line was ready for use, line tip confirmation and any complications. ! Provide details of CVAD removal including removal date, procedure list, intact tip, complications and reason for removal ! Provide detail on infection rates per thousand line days, including what was isolated, when and line type ! Collect line day data for all patients, regardless of the patient admission status. It was agreed that the hospital was responsible for all lines including those outpatients being managed in the community ! Be incorporated into the existing electronic medical record ! Be simple to use and easy to access. In 2011, an insertion form was developed in Power chart for use by medical staff; mandatory criteria were developed so that consistent information was collected for all patients. The form includes simple tick boxes with the option to free text if required, access to the insertion form is restricted to medical staff only, however all clinical staff have access to the information in a ‘read only’ format. Education was provided to the general surgeons, anaesthetists and interventional radiology staff on its use. To ensure buy in from the medical staff and to reduce double documentation of information, it was agreed the electronic document would replace the normal operation record sheet that is currently used for all operating room procedures. In 2012 a removal form and an infection form were also developed, these forms are both linked to the insertion form, once these forms are opened all details of the line insitu are available. This allows staff to complete forms easily and quickly. Monthly reports of CVAD documentation were sent to Department Heads. Patient details were provided on any CVAD’s not documented. Staff are required to enter the information into the patients chart retrospectively. Initially the Project Officer agreed to enter the removal data for the Paediatric and Neonatal Intensive Care Units as these units do not routinely use Power chart, this has since been rectified and from January 2014 these departments are now also completing the removal forms. Results: Documentation of CVAD insertions increased from 44% in July 2011 to 90% in July 2012. Insertion documentation has been maintained over 90% since then. Documentation of removals for medical staff increased from 75% in July 2012 to 100% in August 2013, and has remained above 90% since then. Documentation of removals for nursing staff has increased from 15% in January 2013 to over 75% by December 2013. We are now able to accurately capture and report inpatient and outpatient CVAD infection rates per thousand line days using the patient’s electronic medical record. Conclusion: Capturing line days has previously been extremely time consuming and user dependant, by developing a simple and easy to use electronic document, we are now able to collect accurate line days and have accurate documentation in the patients’ medical records 2425 Transforming Health: Creating A Culture Of Quality Improvement Tristan Vasquez* 1 1 Transformation and Quality, Melbourne Health, Melbourne, Australia Objectives: Faced with the challenge of ever increasing demands, Melbourne Health (a large metropolitan healthcare provided in Melbourne, Australia) needed to actively create a culture of quality improvement. The organisation specifically wanted to develop its workforce, improve the quality and safety of services, develop and encourage strategic relationships, foster innovation, and build a sustainable organisation. Methods: The Transformation and Quality team, composed of business improvement professionals, was tasked with leading the implementation of the strategy. Given the ambitious aim of developing cultural change multiple approaches were deployed, such as the commissioning of online and face-‐to-‐face improvement training packages, deploying a sustainability model for improvement work, a promotional campaign to accompany the strategy, the design of a powerful business intelligence and reporting tool, aligning clinical improvement to Australian national standards, and launching a reward and recognition programme. Results: Quality and safety targets are being met, a recent periodic review (accreditation) was very successfully passed, hundreds of staff have been trained and consequently there has been a proliferation of improvement projects throughout every practice area, and a culture of continuous improvement is palpable within the organisation. Conclusion: Melbourne Health has embedded a strategic approach to deliver higher quality services more effectively and efficiently resulting in better outcomes for patients and staff. 2432 How Visual Management For Continuous Improvement Might Guide And Affect Hospital Staff – A Case Study Waqar Ulhassan* 1, Ulrica V. T. Schwarz1, Christer Sandahl1, Johan Thor1, 2 1 LIME Department, Karolinska Institutet, Stockholm, 2Jonkoping Academy for Improvement of Health and Welfare, Jonkoping University, Jonkoping, Sweden Objectives: Visual management tools such as whiteboards, often employed in Lean thinking applications, are intended to be helpful in improving work processes in different industries including healthcare. It remains unclear, however, how Visual Management (VM) is actually applied in health care Lean interventions and how it might influence clinical staff. We therefore examined how Lean-‐inspired VM using whiteboards for Continuous Improvement (CI) efforts related to hospital staff members’ work and collaboration. Methods: Within a case study design, we combined semi-‐structured interviews, non-‐participant observations and photography on two cardiology wards (Ward-‐I & Ward-‐II). The collected data was analysed using content analysis to describe the case and interpret the findings. Results: The whiteboards as VM tools helped the staff to participate in CI work any time regardless of CI meeting times. The fate of VM differed between the two wards; in Ward-‐I, it was well received by staff and enhanced continuous improvement efforts, whereas in Ward-‐II, it was not applied properly as it was mixed with another Lean activity named ‘morning meetings’. The two activities having different objectives couldn’t work and CI work with VM was abandoned whereas the ‘morning meetings’ were continued in separate teams in the ward. Ward-‐I was successful in implementing and sustaining the overall Lean intervention, whereas Ward-‐II could only implement Lean partially and could not sustain the results. Conclusion: Visual management may enable staff and managers to distribute communication across time and facilitate teamwork by enabling the inclusion of team members who are not present simultaneously; however, its adoption and value seems contingent on finding a good fit with the local context. 2468 What Do Hospitals In São Paulo State Do Regarding Safety Issues: An Intended Census Ana Maria Malik1, Laura Schiesari* 1, Georges Maguerez2, Maria Laiz Zanardo1 1 Fundação Getulio Vargas, 2Fundaçao Getulio Vargas, Sao Paulo, Brazil Objectives: Scientific question: are quality and safety policies really used in São Paulo State Hospitals? Objectives: To identify how hospitals in São Paulo State are organised in order to provide safe quality care; to identify the degree of implementation of safety initiatives in these hospitals, as well as the strategies used. Methods: A comprehensive questionnaire, designed in order to assess the main actions and activities related to quality and safety taking place in the organisation has been developed by the research group and then validated by quality and safety experts, as well as tested in 40 hospitals. Either their CEOs or somebody appointed by this manager answered the questionnaire after a first personal contact. Ten were answered in the presence of an interviewer; the others were sent and returned by e-‐mail. Data analysis allows an assessment of individual variables as well as the association among them. Results: Hospitals were resistant to answering the questionnaire, especially private for profit ones. Even though there is an extensive federal legislation regarding safety in hospital care, many simple measures are not yet undertaken by the majority of hospitals who accepted to answer the questionnaire. Conclusion: The Brazilian safety journey is just starting. There´s much room for improvement, even in the state where most accredited hospitals are located. After this test, the questionnaire will be improved, so that it can be applied to the remaining São Paulo State 848 hospitals. The information provided by this research will enable improvement of health public policies regarding this issue. 2480 Risk Management Assessment As A Means Of Fostering Safety In Healthcare Laura Schiesari* 1, Denise Schout2, Evandro T. Mesquita3, Fabio Peterlini4 1 ANAHP, 2STconsulte, Sao Paulo, 3Hospital Pró-‐Cardiaco, Rio de Janeiro, 4Hospital São Camilo, Sao Paulo, Brazil Objectives: The National Association of Private Hospitals (ANAHP) was founded in 2001 by 23 leading organisations perceived as delivering high quality care in Brazil. ANAHP assembles 55 excellence private hospitals from 5 regions today. Its mission is to "represent the legitimate interests of member hospitals developing an image of added value, through novel initiatives and excellence models, increase the quality of medical and hospital services in Brazil". Work groups are part of the main activities of ANAHP. Such groups allow professionals from different hospital members to share experience so as to improve their hospitals´ practices either in hospital care or in management. Different aspects of care delivery are discussed depending on the challenges being faced by hospitals. According to the theme being approached, either a specific temporary group discusses the subject further or a particular study is designed so as to gather information from the participating hospitals. This permits accelerating the knowledge share aiming at implementing new and innovating strategies in a short period of time. The aim of this abstract is to assess ANAHP´s hospitals risk management activities, as well as how those hospitals manage risk and patient safety. Methods: In 2010, a questionnaire containing different aspects of Risk Management and Patient Safety was developed. The questionnaire contained the following domains: Risk management within the hospital, incident reporting, specific incidents, such as falls, pressure ulcers, phlebitis, allergies, thromboembolism, bronco-‐aspiration, transfusion reactions, accidental extubation, medication errors, safety in surgical procedures. Each domain was assessed according to its specificities, but a few aspects were common, such as incident classification practices, incident analysis, existence of a Committee in charge of its evaluation, use of indicators, patient and family orientation. This questionnaire was sent to all 39 hospitals. After 2 recalls, 32 (82%) hospitals answered. Data from all hospitals was gathered and presented in percentage of compliance with each aspect assessed. Results: Hospitals have good practices in terms of pressure ulcer, falls, medication errors and allergies, whereas phlebitis, thromboembolism and broncho-‐aspiration evidenced lower levels of compliance. There is room for improvement in many aspects, such as Patient and family information, patient record standards ´compliance. The disclosure of group performance allowed hospitals to discuss their individually performance within each organisation, some of which incorporate many aspects addressed in the questionnaire in their quality and safety programs. Conclusion: When this study was conceived, there was no national patient safety policy. In April 2013 a National Patient Safety Program was launched and safety principles were reinforced and are now being spread throughout the country. The questionnaire mentioned above has been reviewed and will be sent to hospitals so as to assess the evolution of their practices. This will allow hospitals in general to assess their local programs and will thus provide more information about the impact of patient safety initiatives in leading hospitals in Brazil. 2498 Bedside Care Teams: Disseminating The Concepts Of Patient Safety Aline P. Mello1, Cristina S. Mizoi1, Adriana P. Silva* 1, Samara P. Silva1 1 Quality and Safety, Sociedade Beneficente Israelita Brasileira Albert Einstein, Sao Paulo, Brazil Objectives: The Bedside Care Teams consists of multidisciplinary care team professionals that make decisions related to practice focusing on patient, professional, and environment safety. Methods: Safety indicators were spreading during meetings, and the Bedside Care Teams dedicated to detailing the problems and performing brain storming for solutions. Possible solutions included educational videos, lectures by experts, questionnaires, acquisition of material resources, training and updating documents that guide professional practice. Bedsides approaching issues of the hospital of healthcare professionals, the team feels valued, responsible for the results and participating in decisions, increasing the chances of participation of the other co-‐workers. Results: Currently there are 18 Bedsides Care Teams that were developed around 5 actions by group about patient, collaborative, and environment safety, policies and care practice. Near miss measurement was adopted like a principle point as an improvement to safety culture. Was obtained an increase of around 100% (from 1,439 to 3,303) in the number of notifications of this type of adverse event. Conclusion: Care Teams have become a point of convergence between the hospital’s leaders and the care team. The main result was the empowerment of the care team to discuss, analyse and make decisions that affect the everyday practice and the institutional goals. 2502 Identification And Classification Of An Adverse Event Using An Adapted Who International Classification For Patient Safety (ICPS) Taxonomy Carla Fatima D. P. Nunes1, Leny Cavalheiro1, Daniella C. Chanes1, Paola B. D. A. Andreoli* 1 1 Quality, Safety and Environment Division, Israelita Albert Einstein Hospital, Sao Paulo, Brazil Objectives: Classify incident reported by type, in a tertiary private hospital in Brazil, using adapted taxonomy from World Health Organization’s (WHO) International Classification for Patient Safety (ICPS). Methods: All incidents reported electronically in 2013, involving patients in a private hospital in São Paulo – Brazil, were evaluated by experts from a risk management area. All reports that didn’t can be classified like an incident, according World Health Organization’s definition were removed. Those events were evaluated and classified using an adapted taxonomy from World Health Organization’s (WHO) International Classification for Patient Safety (ICPS) (developed by the risk management group to address the specificities of the types of services offered to patients and potential incidents during the patient care). The data were summarised using descriptive statistics. Results: In 2013, 7643 incidents were reported electronically. These incidents were classified in incidents/near miss (n=3300 – 43,18%) and adverse events (n= 4343 -‐ 56,82%). In the first level, these incidents were classified by type. Incident classified as Near Miss, included clinical administration18,79% (n=620), clinical process/procedure 10,91% (n= 360), documentation 4,00% (n= 132), healthcare-‐associated infection 0,03% (n= 1), medication/IV fluids 47,76% (n= 1576), blood/blood products 1,18% (n= 39), nutrition, oxygen/gas/vapour 0,39% (n= 13), medical device/equipment 12,09% (n= 399), behaviour 2,52% (n= 83), patient accidents 1,48% (n= 49), infrastructure/building/fixtures 0,3% (n= 11), and resources/organisational management 0,33% (n= 10). Adverse events were classified as clinical administration 9,37% (n= 407), clinical process/procedure 40,11% (n= 1742), documentation 4,00% (n= 132), healthcare-‐associated infection 0,03% (n= 1), medication/IV fluids 47,76% (n= 1576), blood/blood products 2,65% (n= 115), nutrition, oxygen/gas/vapour 6,01% (n= 261), medical device/equipment 5,30% (n= 230), behaviour 4,33% (n= 188), patient accidents 9,10% (n= 395), infrastructure/building/fixtures 0,67% (n= 29), and resources/organisational management 0,21% (n= 9). Conclusion: The adaptation of the World Health Organization’s (WHO) International Classification for Patient Safety (ICPS) taxonomy is a useful reference model for the classification of incident reporting. Furthermore, the use of a common reporting form at the institutional level is recommended for reducing variations in reporting incidents and facilitating the efficient collection and analysis of patient safety data. 2521 Assessment Of The Surgical Safety Checklist: A Before And After Study Design Maristela N. Ramos1, Carlos M. Antunes* 2, Edna S. Beck3, Fernanda R. Gimenes4 1 Unidade de Terapia Intensiva, Hospital Estadual Sumaré, 2Hospital Estadual Smaré, Unidade Referenciada Adulto, 3 Hospital Estadual Sumaré, Central de Material , Sumaré, 4Universidade de São Paulo, Docente, Riberão preto, Brazil Objectives: To assess the completion of the surgical safety checklist before and after a Nurse Manager intervention. Methods: A before and after study design was performed in a Surgical Centre of a Brazilian State Hospital. We performed medical Record audits in February 2011, before the intervention; and in two moments after the intervention: in September 2011 and in September 2012. Data were collected through a structured instrument developed for the purposes of the study. The sample consisted of 402 medical records of patients undergoing surgery in February 2011, by 348 medical records of patients undergoing surgery in September 2011, and by 497 medical records audited in September 2012. The interventions involved verbal orientation to nursing staff and the development of guidelines. Results: All medical records audited in these periods contained the surgical safety checklist. Before the interventions, 18% of these checklists were incomplete. After the interventions, 26% of medical records were incomplete in September 2011. Most of them were related to the admission of a new group of employees. In September 2012, however, only 5% of all medical records audited were found incomplete. Conclusion: There was a reduction in the number of incomplete surgical safety checklist over time. There is a need for continuous training of all health care professionals acting in the operating room, and especially of the new employees hired in the unit. References: Scarpo, A. F; Ferraz A. C. Auditoria em enfermagem: Identificando sua concepção e métodos. Rev. Bras. Enferm, Brasília 2008 maio-‐junho; 61 (3): 302-‐5. 2528 Computerisation Of The Diet Census At Hospital Estadual Sumaré Marcela R. Santos1, Luciana G. S. Gullo2, Fabio R. Gonçalves3, Carlos E. M. Antunes* 4 1 Coordenação de Enfermagem, 2Nutritionist, 3Systems Analyst, 4Nurse, Hospital Estadual Sumaré, Sumaré, Brazil Objectives: To guarantee the providing nutrition to the patient according to medical prescriptions, ensuring that diet therapy is applied correctly and safely. Methods: The Service of Nutrition and Dietetics (SND) is responsible for providing diets to patients and their companions of Hospital, ensuring a balanced and adequate sanitary hygienic conditions food. The supply of this food contributes to the treatment of inpatient having great importance in the maintenance and/or recovery of nutritional status and health of the patient. For this supply reaches the patient correctly and securely is necessary that the census of diets is correct and in accordance with the prescription and patients are interned in beds as described in the census. The Hospital had an non-‐computerised census which served meals satisfactorily, but in the meantime for the issuing of transcripts, it went through several processes which endangered the accurate information ahead prescription, that means that the physician performed the prescription, the nurse transcribed it and the SND performed the issuance of labels manually, including information regarding the bed, handwritten form in each of the labels. Results: Based on the problems found across the transcription of the census by nursing teams, the Information technology (IT) Department of Hospital developed a report within the ERP (Enterprise Resource Planning) used by the institution capable of capturing the information contained in the prescription and the patient record. The information to be captured were selected according to the needs of the SND. The issuance of the census is based on information from the last diet prescription performed by the physician. If there is a need for some type of change in diet such as suspension of fasting, which is not an immediate requirement, the process of computerisation provides that you can perform the request of single diets to patients, nurses must make the request specific spot at in the system until the physician performs the prescription, to ensure feeding or fasting for these patients. Both spare patients' requests and requests for companion’s meals have a census and print labels automatically linked to the system containing patient information (full name and date of birth), the prescribed diet and any observation related to the diet that might be prescribed in the chart. This computerisation process also allows the issuance at any time, a report of patients not yet been prescribed by the doctor, allowing an alignment between the medical and nursing care and SND, with punctuality and quality. Conclusion: The multidisciplinary work demonstrates unremitting health systems improvements. The process of computerisation of census diet allows these improvements to all professionals involved as the loyalty of the fulfilment of medical prescriptions, non-‐transcription by nurses, the independence of SND to start their daily activities and, especially, the quality assurance of the process to the patient, who is the greatest beneficiary. 2538 Automated Methods Of Adverse Events Detection: A Critical Review Of The Literature Christian M. Rochefort* 1, 2, 3 1 Epidemiology, Biostatistics & Occupational Health, 2Ingram School of Nursing, 3Clinical & Health Informatics Research Group, McGill University, Montreal, Canada Objectives: Adverse Events (AE) are estimated to occur in 2.9% to 16.6% of all acute care hospitalisations, and studies suggest that 30% to 58% of all AE are preventable. Preventable AE are associated with significant mortality, morbidity and cost. To help hospitals assess the success of preventive measures, there is a need for accurate and timely methods for detecting and monitoring AE. However, current AE detection methods are inadequate. Indeed, manual chart review is a time-‐ consuming, resource-‐intensive and costly process. As for administrative data, they are well known for having low sensitivity and limited positive predictive value for identifying AE. With the increasing availability of electronic medical records, and the development of automated methods for encoding and classifying electronic narrative documents, such as natural language processing, there are new opportunities to identify potentially better methods of AE detection. The purpose of this literature review was to critically assess studies examining the accuracy of these methods. Methods: Relevant studies, published in any languages, were identified through an extensive search of the PubMed database (January 1990 – January 2014) using combinations of selected keywords. Additional studies were identified using bibliographic review of the key articles retrieved, and the ‘related articles’ feature of PubMed. Studies were included in the review if they: a) were conducted in an inpatient setting, b) described an automated AE detection method, and c) assessed the accuracy of the automated method of AE detection in comparison with a gold standard assessment of the medical chart. The methodological quality of each study was assessed using published criteria. Results: We identified 47 studies assessing the accuracy of automated method of AE detection. Studies based on electronic triggers (e.g., abnormal laboratory results, the prescription of an antidote drug) tend to have low sensitivity and positive predictive value for identifying AEs. Other studies used Natural Language Processing (NLP), which refers to automated methods for converting free-‐text data into computer-‐understandable format. Two broad approaches to NLP were identified in the literature: symbolic and statistical techniques. Symbolic (or grammatical) NLP techniques use the characteristics of the language (i.e. semantics, syntax and the relationships among sentences) to encode free text documents, whereas statistical techniques use the frequency distribution of words to automatically classify a set of documents into one of a discrete set of pre-‐defined categories. The accuracy of these NLP techniques varies with the complexity of the NLP task to accomplish and the richness/completeness of the data employed. The methodological quality of the studies also varied widely. Conclusion: NLP techniques promise improved accuracy by allowing for the capture and classification of the rich information contained in free-‐text clinical narratives. NLP techniques of AE detection also offer a potentially cost-‐effective alternative to traditional methods. However, their accuracy varies widely, thus limiting their widespread utilisation in the inpatient settings. 2551 Implementation Of A Plan Of Care In Situations Overcrowding In A Unit Of Emergency Ana Julia S. Medeiros1, Carlos Antunes* 2, Carina Ruella2, Karla Caproni2 1 uti, 2Emergency, Hospital Estadual Sumare, Sumare, Brazil Objectives: Overcrowding in a Hospital Referenced Emergency Adult directly impacts the clinical management and care quality, may cause delay in the care of acute patients and increase mortality. It is characterised by patients in the hallways and residence time unit above six hours. The objective of this work is to implement a care plan in situations of overcrowding in the unit Referral Emergency Adult State Hospital of Sumaré. Methods: This is an exploratory and descriptive quantitative study. The team referenced the adult emergency began this work in July 2013, at the state hospital of Sumaré, a public teaching hospital in São Paulo, with 260 beds, with reference to the cities around them, with 1.1 million inhabitants. The team consists of doctors and nurses. Was established in the treatment protocol in this unit emergency a patient in the hallway for more than six hours characterised overcrowding and that from the fourth patient in the hallway for more than six hours will trigger an emergency code for the given situation "code purple". Results: If the Purple code triggered the nurse on duty, the representative must seek inpatient beds for patients referred urgently to the hospital, which may result in cancellation of admissions for elective surgery, opening extra beds in the ICU and inpatient not in customary units. Nursing service/doctor will then work with the admissions priorities aiming rapid medical diagnosis within 6 hours, referrals Exam (image or laboratory) to determine diagnosis and therapeutic procedure, plus transfers to inpatient units that should happen priority of beds in the shortest possible time, and the high medical evaluation will be prioritised for patients. At the beginning of each shift a visit called "Round" by nurses in order to guide the nursing staff will be held to act in cases of overcrowding, speeding care and maintaining quality of care Conclusion: The implementation of a plan of care in situations of overcrowding aims to streamline care in the emergency unit of length of stay of patients and to ensure safe and quality care in a humane way. References: Bittencourt, Roberto José A superlotação dos serviços de emergência hospitalar como evidência de baixo desempenho organizacional. / Roberto José Bittencourt. Rio de Janeiro: s.n., 2010. 2554 Safety Administration Of Contrast: Imaging State Hospital Sumaré Ana Julia S. Medeiros1, Karen L. Vasconcellos2, Antonieta K. Kakudo3, Carlos M. Antunes* 4 1 UTI Adulto, Hospital Estadual Sumare, Sumare, 2Supervisora de Enfermagem Ambulatório, Hospital Estadual Sumare, Sumaré, 3Professora Dra. da Faculdade de Enfermagem da Unicamp, Unicamp, Campinas, 4Emergencia Referenciada, Hospital Estadual Sumaré, Sumaré, Brazil Objectives: To describe the process of creating and deploying barriers to minimise events or circumstances that may result in unnecessary damage to the patient. Methods: This is an experience report on implementation of strategies in the imaging industry. In this Health Institution, from 2005, all patients were being assessed and prescribed by the radiologist before the administration of contrast, so that nursing could manage and check his administration safely. Since the beginning of activities in the sector in 2002, the survey was conducted to allergic outpatients and in 2008 also included allergic to search for inpatients following the occurrence of a death from severe reaction, and in February 2012, was included renal patient profile. Also, from that year, the process has been refined classification of allergic reactions presented after contrast administration, being classified as its severity (mild, moderate and severe) and for symptoms (expected and unexpected). This classification allows us to assess whether the choice of contrast was adequate or not the patient. Results: Since 2008 not registered any serious allergic reaction to damage to the hospital and/or outpatient. Comparing the years 2012 and 2013 are: the reactions presented were classified as mild in 90% and 71% as moderate and 10% and 29% respectively. And as expected for symptoms in 76% and 88% and not expected 24% and 12% respectively. In both years analysed, the unexpected symptoms refer the complaint "metallic taste", which is not reported in the literature as a symptom expected but very often verbalised between the patient's complaints. Conclusion: It is believed that allergic correctly applied research associated with the assessment of physician prescribing contrast, proves to be an efficient strategy to filter and direct the radiologist to determine what type of contrast should be used. With simple and inexpensive measures you can ensure quality of care and avoiding iatrogenic errors to patients. In this case the patient is also considered a barrier in his treatment because he participates, answering questions and signing information given/issued. 2571 Awareness Towards Falls Prevention To Reduce Patients’ Harm: A Report Of Nurse Staff Compare With Three Academic Affiliated Hospitals In North Taiwan Mei-‐Jung Wu* 1, Chaung Juan wu2, Yih-‐Giun Cherng1 1 Medical Quality of Department, 2Nursing Department, Taipei Medical University, Shaung Ho Hospital, New Taipei City, Taiwan Objectives: Patient Safety is regarded as an important quality indicator of medical healthcare. Reducing physical harm from Patient Safety is regarded as important as an important quality indictor of medical healthcare. Reducing physical harm from patient falls has become a national policy issue. The aim of this exploratory survey was to identify the nurse staff’s awareness of prevention inpatients fall in three academic affiliated hospitals. Two hospitals established from 1976, 1998, compared with a brand new hospital that was built in 2008. This survey was to measure awareness of the high risk group the medications typed relate to falls, medication condition, hazard environment and potential risk factors and provide nursing intervention consequences of falls among different hospital nurse staff. Methods: A cross-‐section study was performed, from January 1st, 2012 through to September 31st, 2012. Each nurse completed a 61 item structure questionnaire. The questionnaire included demographic data and six dimension (high-‐risk group medical condition medications, hazard environment and nursing intervention). The level of awareness to prevent falls was from 1 to 10 (extremely lower to extremely higher). All data analysis were done on sing SPSS version 17.0 Frequency, Distribution, Descriptive mean, Standard deviation ANOVA. Results: A total of 900 participants of the questionnaire were distributed by nurse staff in three teaching hospitals and 888 completed the form returned during this time, a good response rate of 97.9%. Average age was 28.1 (SD±.94) and majority of participants were female (N=881.99.2%). 78.8% of participates were single. Six to ten of respondents work in general ward (N=583.65.6%). Approximately 92.5% of responds work as a nurse. As a result, overall the average of awareness toward falls prevention was 7.02 (SD±1.36). The highest score was patients’ medical condition (7.30, SD±1.46). The lowest score was potential risk factors (6.55, SD±1.83), the nurse who work in the youngest hospital identify the high risk factors better than the others (F=7.153,P<0.001). All of the nurse staff ignore the different gender caregiver was the cause effect inpatient falls (5.15, SD±2.5). The other hand, they represented awareness toward of medications type relate to the falls (F=11.861,P<0.001). However, the follows type 2 medication (Antipyretic and tetracycline) misleading the middle hospital nurse that it cause to falls. Conclusion: The healthcare provider apply a high Quality care is the important issue to reduce the harm form the incidence during hospitalisation. Patient fall lead up to increase the length of staycause of disability and high costs.There are various facto rs related to fall of inpatients. Bases on the result, the healthcare provider enhanced all and provided valuable database to identify the important issues. The nursing staff provides not only high-‐quality but also to reach the goal of patient safety with patients during hospitalisation. References: Wiens, C. A., Koleba, T., Jones, C. A., & Feeny, D. F.(2006).The Falls Risk Awareness Questionnaire: Development and Validation for Use With Older Adults. Journal of Gerontological Nursing,32(8), 43-‐50. 1102 Central-‐Line Associated Bloodstream Infections In Private Intensive Care Units In Brazil Eduardo Vieira Neto* 1, Adriana D. M. Cavalcanti1, Daniele P. da Silveira1, Raquel M. Lisbôa1 1 Gerência de Avaliação da Qualidade Setorial, National Regulatory Agency for Private Health Insurance and Plans, Rio de Janeiro, Brazil Objectives: Central line associated, laboratory-‐confirmed primary bloodstream infections (CLABSI) are an important cause of morbidity and mortality in Intensive Care Units (ICU), although strategies to reduce their incidence are well known. Consequently, CLABSI rates in ICUs have been included in several hospital quality indicator initiatives from industrialised countries1. As part of a pilot program conducted by the National Regulatory Agency for Private Health Insurance and Plan (ANS), in the first semester of 2013, to monitor hospital quality of care in the private health sector in Brazil, CLABSI rates and central line utilisation ratios were included as patient safety indicators. We determined the results of these indicators in adult, paediatric and neonatal ICU of hospitals participating in this program. Methods: The participating hospitals voluntarily joined the program after being invited by hospital associations and health insurance companies with the support of ANS. Technical specifications for the indicators were made available on ANS website. Number of CLABSI, central line-‐days, and patient-‐days were informed monthly to the Federal Agency through an online form called FormSUS. Data were imported into Stata 12.1 (Stata Corp, College Station, TX) for analysis. Results: During the six-‐month period, 458, 65, and 97 CLABSI were informed by 57 adult, 23 paediatric, and 27 neonatal ICU, for an aggregate of 104,555, 12,403, and 13,081 central line-‐days, respectively. The pooled means were 4.38, 5.24, and 7.42 infections per 1,000 central line-‐days for adult, paediatric, and neonatal ICU. For an aggregate of 193,287, 22,742, and 33,987 patient-‐days reported by adult, paediatric, and neonatal ICU, pooled means for central line utilisation ratios were determined as 53.44%, 48.06%, and 36.36%. There was a negligible correlation between CLABSI rates and central line utilisation ratios for adult ICU (r=-‐0.0116), and a weak positive correlation for paediatric (r=0.2086) and neonatal ICU (r=0.2384). The results obtained by two-‐way ANOVA indicate that hospital size and complexity did not influence CLABSI rates significantly (p=0.3696). Conclusion: CLABSI rates for the private hospitals participating in this surveillance program were not different from data of a larger group of public and private hospitals disclosed by the National Health Surveillance Agency (ANVISA)2. Although the rates were considerably lower than those reported by the International Nosocomial Infection Control Consortium (INICC), for 2004-‐20093, they were significantly higher than those reported by the US National Healthcare Safety Network, for 20114. These findings may indicate that compliance to best-‐practice central line maintenance care bundle has not yet achieved a maximal level in private hospitals in Brazil. References: 1 Agency for Healthcare Research and Quality (AHRQ). Guide to Patient Safety Indicators. 2007 March 12, 2007 [cited 15/08/2010]. Version 3.1:[Available from: http://www.qualityindicators.ahrq.gov/downloads/psi/psi_guide_v31.pdf] 2 ANVISA. Indicador de Infecção Primária em Corrente Sanguínea: Análise dos dados das Unidades de Terapia Intensiva Brasileiras no ano de 2011. Brasília; 2012 Outubro de 2012. 3 Rosenthal VD, Bijie H, Maki DG, Mehta Y, Apisarnthanarak A, Medeiros EA, et al. International Nosocomial Infection Control Consortium (INICC) report, data summary of 36 countries, for 2004-‐2009. Am J Infect Control. 2012 Jun;40(5):396-‐407. 4 Dudeck MA, Horan TC, Peterson KD, Allen-‐Bridson K, Morrell G, Anttila A, et al. National Healthcare Safety Network report, data summary for 2011, device-‐associated module. Am J Infect Control. 2013 Apr;41(4):286-‐300. 1456 Process Mapping And Risks: An Experience Report About The Implementation In The Management Of Hospital 9 De Julho Karina Banhos* 1, Ana Paula T. Mikulenas1, Regina Tranchesi1, Marcella N. Gumieiro1 1 Quality Management Department, Hospital 9 de Julho, São Paulo, Brazil Objectives: Develop and implement a method to minimize the risks in the institution, with proactive approach, to be utilized as a management tool. Methods: This study is a descriptive experience report, with quantitative and qualitative analysis, developed in Hospital Nove de Julho and its Specialised Medicine Center, a private institution in São Paulo, which has 310 hospital beds and 44 medical offices. The tool was implemented from November 2013 to February 2014, after an internal validation of the process and risks map by the institution quality manager. The implementation of the tool was proposed through daily discussions with the managers of each unit and all people involved in the process and identified risks. The employee’s knowledge was used to develop the risk map, causing it to be a representation of how they perceive their work environment. After constructing each map, they were presented to staff in local training and subsequently fixed as panels in their units. The map processes and risks For the construction of the risks map some parameters proposed by Vieira (1998) were used, and other adapted models, with the following steps: 1º knowledge of the work process in the analysed site (map in the care process); 2º identification of existing risks at all critical stages of work and their classification; 3º identification of preventive measures (barriers), their method of control and contingency actions. Results: The work method used found that the risks present in the units were not perceived and treated preventively as they should. There was a difficulty to differentiate the concepts of "Barriers and Contingencies" applied to the identified risks. Another critical factor was the lack of control method on the barriers identified in critical processes, which led not knowing for a fact the preventive barriers in existing procedures were indeed effective. Conclusion: We conclude that this exercise was critical in understanding risk with preventive purpose for the hospital staff. The process created awareness about the issue between the managers and increased the interest on the subject of the employees. The utilisation of posted maps in units increased the curiosity of employees in reading the instructions and comparing to their usual practices. Risk mapping is a reminder that there are risks in work areas, and their identification provide increased safety in patient care. 1603 Evaluating The Quality And Safety Of Perinatal Care Using Administrative Data: A Systematic Review And Retrospective Cohort Study William L. Palmer* 1, Paul Aylin1 1 Imperial College, London, UK, London, United Kingdom Objectives: To investigate the ability to use administrative data to evaluate the quality and safety of perinatal care at a provider level, focusing on the ability of measures to identify important effects in a robust fashion. Specifically, the study was designed to compile existing performance measures and use a subset of these on data from hospitals in England, investigating issues such as the influence of organisational factors (e.g. staffing levels) and coding practice. Methods: The first stage involved a systematic review of original studies that applied, evaluated or validated obstetric-‐specific indicators based on administrative data. Thereafter, eight indicators – spanning both process and outcomes measures and mother and neonate – were applied to English data from March 2011 to April 2012. Logistic regression analyses were used to adjust for case-‐mix, and funnel plots to look at potential outliers. The effect of variation in staffing levels and hospitals’ coding practice was tested using a range of proxies and multi-‐level regression models. Results: Literature review: The initial search identified 1,670 unique citations of which 80 studies had used administrative data to evaluate perinatal care. There has been a steady growth in the use of such indicators; however, few studies are well described. Many countries have used obstetrics-‐specific indicators although each study has only focused on a very small subset of measures. The literature review described in the previous chapter identified 24 maternal, 9 delivery, 11 neonatal categories of indicators with the potential to be applied to administrative data in England. Retrospective cohort study: We identified 669,617 maternities and 678,785 live and still births across 229 provider sites. The indicators were sufficiently sensitive to identify variations in performance as recorded in the data, with 550 occurrences of sites performing statistically differently than expected at the 99.8% significant level across the eight indicators. For example, rates of emergency readmissions for neonates ranged, by site, from 1.6 to 14.1%. Yet two key coding issues that were central to the assumptions for identifying complications and adjusting for case-‐mix explained only a minority of the differences in performance against the measures. At the site-‐level there is a strong positive association between neonatal and maternal infections (r = 0.259, p < 0.002). Across the sites and at the 99.8% confidence level, there was also a positive statistically significant correlations between perinatal mortality and both neonatal infections (r = 0.355) and maternal readmissions (0.218). We found a negative correlation between staffing levels and perinatal mortality (p=0.05), suggesting that increasing the number of midwives may reduce mortality rates. Conclusion: This study represents the most comprehensive review of obstetric care in England using administrative data, and even provided evidence – through evaluating the effect of staffing levels – that complication rates may be influenced by how maternity services are resourced. This study is also the first to evaluate the effect of differences in coding practice on such measures, with these factors appearing to only partially explain the variation in performance. The work shows that administrative data can be used to indicate potential concerns around performance across some of the different aspects of quality and safety of obstetric care. 1658 The Practice Of Epidural Anaesthesia In Princess Marina Hospital Labour Ward In Botswana: A Clinical Outcome Audit Goabaone Rankgoane1, Gothusang Tawana* 2, Tiny Masupe1, Mooketsi Molefi1 1 Public Health, 2Clinical audits, University Of Botswana, Gaborone, Botswana Objectives: Evidence shows that there may be undesirable effects associated with epidural anaesthesia such as: maternal hypotension, prolonged second stage of labour especially in nulliparous and small cervical dilatation, increased rate of instrumental delivery, high rates of caesarean sections, infant low APGAR Scores, marked motor block, etc. The main objective was to document both the possible undesirable effects and the experiences of staff involved. The audit aimed to: Find out patients’ complications during and post epidural anaesthesia, explore staff experiences in implementing this project and to help the obstetrics department make an informed decision on whether to re-‐start the project or not. Methods: The department of anaesthesia in Princess Marina hospital started a labour anaesthesia project in July 2013. In this project, epidural anaesthesia and combined spinal and epidural anaesthesia are given to women in labour for pain relief. The project was started because it’s part of global anaesthesia practices and for Princess Marina it was long overdue. The project was stopped in November 2013 due to shortage of resources in the hospital, with the plan to re-‐start it later. There was no plan to do monitoring and evaluation when the project started and currently there is no documented project evaluation in place. The audit will provide information to the anaesthesia and obstetrics departments in Princess Marina and to the hospital management on the project performance, its benefits to clients (patients), any resultant complications and areas for improvement. The audit results will inform decisions on whether to continue with the project or to terminate it. All patients who had gone through labour anaesthesia were enrolled, from July 2013 until November 2013. There were 31 patients in total. Only 26 patients had their records available. Patients’ case notes were used to extract the required data. To get the views about the project from health care workers, self-‐administered questionnaires were given to the staff (midwives and anaesthetists) implementing the project. Questions addressed challenges and successes of the project. Results: Three patients (12%) were hypotensive and 84% were normotensive. 20% (5/25) had prolonged labour. The modes of delivery were: four (15.4%) Caesarean sections while two (7.7%) were instrumental deliveries. Spontaneous vaginal deliveries comprised 76.9%. Of those with prolonged labour, three out of five (60%) had a cervical dilatation of 4cm, 40% were 5cm dilated while none were 7cm or more dilated. Nine out of twenty-‐two (40.9%) had cervical tears of varying degrees, fifteen (68.2%) had vaginal tears that needed suturing while four (18.2 %) had an intact perineum. For the neonates, two out of twenty-‐six (7.7%) were born dead while one had a 1-‐minute Apgar score of 5, eighteen had a 1-‐ minute-‐APGAR Score of 8 or more. (More detailed results will follow later). Conclusion: The audit identified a few complications associated with epidural anaesthesia at Princess Marina Hospital, Botswana. In line with previous studies, when epidural anaesthesia was given at smaller cervical dilatations, it was strongly associated with prolonged labour. We recommend that epidural anaesthesia should continue but should be given at bigger cervical dilatations (more than 5) to minimise perineal tears. 1950 Using Intern Audit To Verify Safety Practices In The Use Of Concentrated Electrolytes Juliana Martins1, Laiane Oliveira1, Roberta Flecher* 1 1 Quality Manegement, ACSC -‐ Casa de Saúde São José, Rio de Janeiro, Brazil Objectives: The objective of this study was to measure if the new procedure on concentrated electrolytes solutions is being followed by the employees of a private big hospital in Rio de Janeiro. Methods: The study was descriptive and quantitative. The sample was composed by 28 employees selected randomly. Data was collected in October 2013, through the use of a form called “ROP compliance check-‐list” and compliances tests found in the Requirement Organisational Practices Handbook during an internal audit. Results: Considering the use of concentrated electrolytes identification procedure, 89% of answers were considered adequate. The inadequate answers were related to the change of colour that identifies other kinds of medications. This result is important to show that the nursing team can differentiate the medications available in the hospital, increasing their awareness in electrolytes administration. Considering the procedures related to concentrated electrolytes storage, 93% of the answers were found adequate, which demonstrates that this routine is consistent and the team understands that these medications must be storaged in an area with more control and surveillance, because of the risk. Conclusion: Concluding, this internal audit using ROP compliance check-‐list was able to portray that concentrated electrolyte practice control is solid. The data shows hospital teams are prepared to prevent adverse events of concentrated electrolyte. References: 1. Vincent C. A evolução da segurança do paciente. In: Vincent C. Segurança do paciente: orientação para evitar eventos adversos. São Caetano do Sul (SP): Yendis; 2009. p. 15-‐40. 2. Mendes W, Martins M, Rozenfeld S, Travassos C. The assessment of adverse events in hospitals in Brazil. Int J Qual Health Care. 2009; 21(4): 279-‐84. 3. Cano FG, Rozenfeld S. Adverse drug events in hospitals: a systematic review. Cad Saude Publica 2009; 25(S3): 360-‐72. 4. Hyland, S. & U, D. (2002). Medication Safety Alerts. Institute for Safe Medication Practices Canada [On-‐line]. Available: www.ismp-‐canada.org/download/cjhp/cjhp0209.pdf 5. World Heath Organization, Joint Commission International. Patient Identification. Patient Safety Solutions. Geneva; 2007. [acesso 23 nov 2010]. Disponível em: http://www.who.int/patientsafety/solutions/patientsafety/PS-‐solution2.pdf 6. HARADA et al-‐O Erro Humano e a Segurança do Paciente, 2006. 7. ISMP Brasil –Instituto para Práticas Seguras no Uso de Medicamentos, medicamentos Potencialmente perigosos, 2011. 8. Baker GR, Norton PG, Flintoft V, Blais R, Brown A, Cox J et al. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ. 2004; 170(11): 1678-‐86. 9. PRÁTICAS SEGURAS PARA MEDICAMENTOS DE ALTA VIGILÂNCIA-‐ Jabur, MRL, Castro, EDR, Agostinho, HT, Peleskei, LFP. 10. Institute for Healthcare Improvement (IHI). Trigger tool for measuring adverse drug events. 2004. Disponível em http://www.ihi.org/NR/rdonlyres/8D970CE4-‐BF8C-‐4F35-‐9BC1-‐51358FC8B43F/2222/ TriggerToolforMeasuringAdverseDrugEventsCorrected1. pdf. [Acessado em 7 de dezembro de 2010] 11. Roque HE, Melo ECP. Adaptação dos critérios de avaliação de eventos adversos a medicamentos para uso em um hospital público no Estado do Rio de Janeiro. Rev Bras Epidemiol 2010; 13(4): 607-‐19. 12. Rozenfeld S, Chaves SM, Reis LG, Martins M, Travassos C, Mendes W et al. Adverse effects from drugs in a public hospital: pilot study. Rev Saude Publica 2009; 43(5): 887-‐90. 1960 Use Of Fall Profile And Incidence To Reassess The Current Prevention Practice Of A Paediatric Hospital In Brazil Carla P. A. C. Denser* 1, Denise P. Dalge2 1 Quality Manager, 2Nurse Manager, Hospital Infantil Sabará, São Paulo, Brazil Objectives: The main objective was to get to know the profile and incidence of intra-‐hospital falls and, based on these results, reassess the current practices towards improving safety of paediatric patients. Methods: This was a retrospective, non-‐probabilistic study based on the number of falls notified in the Quality System. Results: The study included 23 medical records of patients who had experienced an intra-‐hospital fall during hospital stay or emergency care in 2012 and 2013. The incidence of falls in the two-‐year period was 0.47 falls/1000 patients-‐day. They were more prevalent in females (57%) and age range distribution was < 2 years (57%), 3 to 5 years (21%), and > 5 years (22%). One hundred percent of the children were accompanied by an adult when the fall occurred. Out of the total, 48% were assessed as having high risk of fall mainly because of age < 2 years. Thirteen percent of the total patients were not assessed concerning risks, because they fell before being seen at the emergency department. Sixty-‐one percent of the falls happened in the patient room, followed by common patient areas (17%), bathroom (13%) and children play areas (9%). Falls from standing position were prevalent (39%), followed by falls from the couch (26%), bed (9%), escalator (9%), crib (9%), bathtub (4%) and toys (4%). Some kind of damage was identified in 78% of the patients. They were distributed into mild damage (61%), fracture (11%), small penetrating wound (11%), penetrating wound with suture (11%), and skin/ mucosa bruising/ injury (6%). In 89% of the medical records there was evidence of education to the child/ family about the identified risks and the defined preventive measures. Conclusion: Even though our fall incidence (0.47/1000 patient-‐day) is below the rates from recent studies (0.56-‐1.0 fall/1000 patient-‐ day), literature data have suggested there is damage in about 62% of the falls. Our incidence of 78% damage from falls made us wonder whether there was under notification of falls without damage and served as a warning for the opportunity of improvement. It was concluded that even hospital specially-‐designed furniture was not capable of preventing falls from beds and cribs, which amounted to 18%. Another critical point was patient and family education concerning preventive measures, considering that 39% of the falls resulted from not following the guidance, which can be perceived as a risk factor. Nurses can lead to the reduction of the incidence of falls and fall-‐related morbidity. To that end, they should know and understand the importance of risk factors, education and compliance of patients and family members with directed and personalised preventive measures. High risk assessment by age range currently in place was not capable of preventing falls in patients aged 2 to 3 years, an age range included in some validated tools. Based on the results of the study, the organisation is planning to implement the use of a more comprehensive, validated and predictive tool of fall risk factors in children as an improvement action for patient safety, in addition to implementing an outpatient assessment, which is not a specific tool currently used in the organisation. 1976 Empowerment Of Middle Management In Improving And Analysis Of Institutional Protocols At Hospital UniMed Santa Helena Izabela F. Tortoza1, Luciane M. Torrano* 2 1 Protocolos, 2Gerência, Unimed Paulistana, São Paulo, Brazil Objectives: Aiming other more flexible approaches that promote participation of the whole hierarchical structure, defined as objective the involvement of middle management in the implementation, as well as restructuring, dissemination and analysis of institutional clinical protocols. Methods: According to Pearson, 1995, notice that the first clinical protocols were developed and implemented in health care in 1980, focused on interest in increasing hospital efficiency. This measure of clinical protocols implementation seemed to soften the variability if behaviour and guarantee the quality of the care provided. Viewed from an organisational environment perspective, protocols seek to standardise actions, control costs, increase efficiency and balance the utilisation of the services. (DENT 1999). With the implementation of the protocols, quality indicators are continuously monitored to ensure clinical practice quality and patient safety. These are monthly compiled, disseminated and discussed with the teams involved to ensure and foster continuous process improvement. This study was conducted at Hospital UniMed Santa Helena, a general hospital located in São Paulo, with 252 beds and predominantly surgical. The implemented protocols followed the following methodology: 1) The need of a protocol in the area, considering the prevalence, severity and cost of diagnosis; 2) Creation of a team to develop protocol, including middle management, who will deal with the real applicability of the results of the protocol; 3) Dissemination of the protocol in the areas concerned; 4) Effective Implementation of the Protocol in the area through the middle management; 5) Analysis and dissemination of the results to the whole organisation through middle management; 6) Relate improvements in the applicability of the protocol along with middle management. Results: The empowerment of middle management at Hospital UniMed Santa Helena has been related to the restructuring of Sepsis Protocol and the development and implementation of protocols Chest Pain and Ischemic Stroke. As a result, an increase in the opening of the sepsis protocol, as well as early identification of these patients through the inclusion criteria and a fall in mortality related to sepsis / Lives Saved. Regarding Chest Pain protocol, we observed a decreasing trend of the main marker which measures the time of administration of Metalyse® after diagnosis of acute myocardial infarction with ST segment elevation. As for ischemic stroke protocol, we also noticed a downward trend in the time of the tomography results from the arrival time on and an increase in the identification of patients eligible for thrombolysis via a contraindications checklist. Conclusion: We conclude that the involvement of middle management in the restructuring, implementation, analysis and dissemination of results, contributes to improved adherence to Bookmarks institutional protocols and subsidises the preparation of an action plan when you have flaws identified When we consider the results as a process of the area itself, we observed a greater involvement and commitment to the critical analysis by the markers when they are presented by the area that got them. In fact, the protocols have institutional coverage, as well as it is noteworthy that the process belongs to the area that has worked on it. So, to make the middle management involved as real management of this information not only integrates the team but also improves its outcomes. 1979 Sedimentation Of Culture Of Notices Of Sentinel Events With Emphasis On Chain Drug In UniMed Santa Helena Hospital Lidiana O. Mendes1, Luciane M. Torrano* 2, Tatiane S. Vieira1, Vanessa E. Silva1 1 Qualidade, 2Gerência, Unimed Paulistana, São Paulo, Brazil Objectives: This work aims to demonstrate the increasing of notifications of the sentinel events from January 2012 to December 2013, emphasising the flaws in drug chain, showing the sedimentation of the safety culture of the institution. Demonstrating the safety culture, one realises that the notification in the institution evolved over the years, having in 2012 an average /month 47 events and 2013 an average / month of 208 reported events. Methods: In order to achieve the rise observed in 2013 the methodology used was the consolidation of the concept and classification of sentinel events and increased incidence of clinical and internal audits. During these assessments the multidisciplinary team was conducted to increase awareness in face of the events and sensitised about the importance of reporting as a tool for identifying organisational and procedural failures that can compromise the expected result and cause harm to patients and professionals. Results: Given this, we can see a significant increase stating from August 2013 which is due to the increased activity of clinical pharmacy validating technically the prescriptions, identifying prescription errors acting as a barrier to serious events. In the amount of reported events in 2013, the highest incidence fell on the Recollect of laboratory tests (48%), followed by failures in drug chain (8%), nosocomial infection (7%) and problems in nutritional therapy (4%). Regarding the drug chain, we realise that the average/month event doubled from 08 events /month in 2012 to 17 events/month in 2013. The above measures as a method for encouraging the reporting of events were effective in the way of settling the safety culture, because according to Queiroz Bezerra, et al. (2012), knowing, understanding, controlling and managing the events is the most effective way to ensure that preventive measures and effective treatments are achieved. Besides these actions, it is crucial to stress that to achieve a growing and consistent reporting, since data from the World Health Organization indicates that one in every ten people who need health care suffers events it is necessary to focus on the process and should not emphasise "who" but "how” these events occurred. Conclusion: Thus, we can conclude that the way to increase the notifications, reaching numbers consistent with reality is the empowerment and involvement of the multidisciplinary team in a culture that seeks to understand and act on the many contributing factors to the occurrence of an event over the reigning culture in health institutions where the error is denied, overlooked, or where there is individual culpability. 2174 Prioritise: Asking Healthcare Professionals About Patient Safety Priorities In Primary Care * 1 2 1 2 Rajvinder Samra , Lorainne Tudor Car , Paul Aylin , Azeem Majeed 1 2 Dr. Foster Unit, Primary Care and Public Health, Primary Care and Public Health, Imperial College London, London, United Kingdom Objectives: It is widely acknowledged that patient safety incidents are as common and serious in primary care as they are in secondary care. To improve patient safety in primary care settings, there is a need to identify threats to patient safety as well as prioritise the areas more commonly associated with patient harm. Healthcare professionals working in these settings (general practitioners, nurses, pharmacists, etc.) are well placed to provide useful, multi-‐faceted feedback on both the threats to patients and the priority areas for targeting patient safety initiatives in primary care. This cross-‐sectional questionnaire study surveyed a range of healthcare professionals working in primary care settings in North-‐West London regarding their patient safety concerns. The objectives of this study are to determine the priority areas for improvements in patient safety, through consultation with healthcare professionals working in primary care. Methods: The questionnaire instrument was subjected to a multistage pilot with individuals working in healthcare research and practice, during which the question phrasing was iteratively improved. For the main study, a sample of 446 healthcare professionals working in primary care settings in North-‐West London was invited to participate in the survey. The participant group includes general practitioners, trainee general practitioners, nurses, and pharmacists. In stage one of the study, participants were asked to nominate the main threats to patient safety in primary care settings, as well as identify strategies which could assist in improving patient safety. Participants were also asked whether they could nominate any examples of routinely-‐collected data that should be shared with healthcare professionals to allow them to improve self-‐monitoring and self-‐directed learning about patient safety events in their own practice. In stage two of the study, the list of priority areas will be re-‐sent to the healthcare professionals with instructions to rank the priorities in order of importance to the goal of improving patient safety in primary care. These results will be scored and given an overall value demonstrating endorsement. The final results will comprise a list of the recommended patient safety priorities for improvement. Results: Preliminary results from pilot phase indicate that healthcare professionals are able to nominate a range of patient safety concerns, which emanate across the different levels of the healthcare system but contribute to patient harm experienced in primary care settings. Participants have described safety concerns relating to medication, access to care, delays in diagnosis as well as with regard to communication between different healthcare teams managing patient care. We are awaiting the full results of the study which will give a more detailed understanding of (a) the nature of the patient safety threats, and (b) the ranked importance of the identified patient safety threats according to healthcare professionals. Conclusion: Using data obtained directly from healthcare professionals working in primary care settings, we can develop a more detailed understanding of the main threats to patient safety. Furthermore, this novel methodology also allows healthcare professionals to rank the priority areas for improvements to patient safety based on their professional experience. This research will help to ensure that patient safety initiatives are targeted in areas recommended by those working in primary care settings. Future work will use this same ranked prioritisation methodology to obtain patients’ views concerning where patient safety initiatives should be targeted. Disclosure of Interest: R. Samra Grant / Research support from: RS is funded by a grant from the NIHR Patient Safety Translational Research Centre. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. The funders had no role in the study design and the collection, analysis, and interpretation of data, the writing of the abstract, or the decision to submit it for the conference., L. Tudor Car: None Declared, P. Aylin Grant / Research support from: PA is partially funded by a grant from Dr Foster Intelligence (an independent health service research organisation). The views expressed in this abstract are those of the authors and do not necessarily reflect the views of the funding organisations. The funders had no role in the study design and the collection, analysis, and interpretation of data, the writing of the abstract, or the decision to submit it for the conference, A. Majeed: None Declared 2343 Surveillance Of Multi-‐Resistant Bacteria (MRB) At Principal Hospital Of Dakar: Assessment Of 1 Year Bécaye Fall* 1, Kowry S. Ndiaye1, Yaya Dieme1, Boubacar Wade2 1 Medical Biology, 2Management, Hospital Principal De Dakar, Dakar, Senegal Objectives: Bacterial resistance to antibiotics is a major public health problem. The control of their diffusion is thus a priority especially in hospitals large antibiotics consumers as Principal Hospital of Dakar. Thus a data collecting system and monthly resistance analyses has been implemented by the Committee against nosocomial infections (CLIN). We present here the results compiled over a year to help guide prevention activities. Methods: This is a prospective study from January 1 to December 31, 2012 in the various departments of Principal Hospital. Every day, multi-‐resistant laboratory isolates are subject to clinical and biological data collection using a questionnaire. These isolates include Enterobacteriaceae producing extended-‐spectrum beta-‐lactamase (ESBL) and depressed cephalosporinase, multiresistant Pseudomonas aeruginosa and Acinetobacter, Staphylococcus aureus Methicillin Resistant (MRSA). Was considered nosocomial origin any infection revealing after 48 hours of hospitalisation. The data are then analysed with Epi Info. Results: Three hundred and twenty three (323) MRB were collected during the study period. The average age was 32 years [4 days, 95 years] with a sex ratio of 1.70. It was essentially ESBL-‐producing Enterobacteriaceae (80%) followed by Acinetobacter multiresistant (11%), ticarcillin-‐resistant Pseudomonas aeruginosa (4%) and methicillin-‐resistant Staphylococcus aureus (4%), respectively. ESBLs were as follows: Klebsiella (55%), E. coli (32%), Enterobacter (11%), and the remaining (2%). Bacteremia was the most common sites (40%), followed respectively by urinary tract infections (37%) and abscesses (16%). Paediatric department was most affected (45%), followed respectively by the Medicine, Intensive Care units (each 23%) and Surgery (9%). A catheter was present in 91% of patients with sepsis and 66% of ESBL infections ESBL-‐producing Enterobacteriaceae were considered as nosocomial origin. Conclusion: This study shows the important place occupied by multi-‐resistant bacteria in Principal Hospital of Dakar. ESBL-‐producing Enterobacteriaceae are by far the most common resistance profile, particularly in nosocomial infections. 2558 The Impact Of The Nursing Records’ Standardisation Over The Loss Of Financial Income Related To Dressing Material Maria Emilia G. F. Del Cistia1, Danivea B. P. Munhoz2, Marilia M. Luvisotto* 2, Claudia R. Laselva3 1 Ambulatorio da Prática Assistencial, 2Unidade de Internação clínica médica, 3Gestão de Pacientes Internados, Hospital Israelita Albert Einstein, São Paulo, Brazil Objectives: To identify and reduce the loss of financial income related to the inadequate or absent register of dressing material; to standardise the correct register in an in a computerised system of nursing prescription and evolution to each kind of wound or dressing. Methods: Transversal descriptive study of quantitative approach done in a private hospital in São Paulo from March to October, 2013; collected data from closed handbook through the nosocomial management system. The study was developed according to the PDCA model and it analysed the loss of financial income of dressing materials from the paying sources due to the absence or inadequacy of the nursing records between March and April related to the percentage of dressing materials mistakenly recorded and to the percentage of the financial charges from the paying sources. An action plan was developed using the quality tool 5W2H as a support through the confection of standardised models of nursing prescriptions and evolutions in a computerised system. The goal established was the reduction of the loss of financial income to 15% in the first two months after the standardisation. It was considered the inclusion of nursing prescription and evolution standardised to the most prevalent kinds of wounds and dressings. In order to verify the results it was considered the auditing done in September and October, 2013, the comparative analysis of the data during the months corresponding to the previous and the post situation – without the system and with the system, respectively – of standard nursing prescription and evolution and the evaluation of these results. Results: It was identified the reduction in the loss financial charges from the paying sources after the implementation of nursing prescription and evolution. The average of the total quantity of material with absent or inadequate prescription or nursing records in the months of March and April was equal to 67.65% and in the months of September and November it was equal to 52.52%. That demonstrates the reduction of 15.13% of the utilised material which showed some irregularity in its record considering the whole Institution. In the units with inpatients (Medical surgical clinics) the reduction was equal to 15.93%; Maternal child equal to 6.74% and Serious patients equal to 17.78%. There was a reduction of the loss of financial charges in 11.61% of the total amount of utilised material which showed some irregularity. In the units of inpatients the reduction was equal 1154%, Maternal child equal to 3.99% and Serious patients equal to 15.51%. Conclusion: The results of this study allow us to conclude that there was a reduction of financial income in 11.61% after the standardisation of the adequate register in a computerised system of nursing prescription and evolution related to dressing, and the reduction of 15.13% in the quantity of dressing material with inadequate or absent register according to the intended goal. 2582 Leading Practice In Venous Thromboembolism Prophylaxis Maria C. Chindamo1, Oneide Silva* 1, Kelvyane Baeta1, Gilvane Lolato1 1 Hospital Barra D'or, Rio de Janeiro, Brazil Objectives: Venous Thrombo-‐Embolism (VTE), which includes Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE), presents high incidence in hospitalised patients and is associated with significant mortality. The implementation of VTE prevention protocol is considered effective at reducing the risk of events and is a major challenge for healthcare institutions. The aims of our study are to present the assistance flow, assessment and monitoring tools, and the efficacy rate of VTE prophylaxis protocols. Methods: A protocol for prevention of VTE was developed in our hospital based on the Safety Zone Program and updated in accordance with the Guidelines of the 8th and 9th ACCP. We established a Multidisciplinary Commission to assign the elaboration of the institutional protocol, promote learning actions with medical staff, conduct periodic audits of the assistance flow, check adherence to protocol, monitor results, and establish communication strategies and participation of patients and families in measures of thromboprophylaxis. The protocol monitoring is focused on the participation of the clinical pharmacist. In clinical units, prophylaxis is assessed by clinical pharmacists within 48h of admission, and reassessed every 48h, based on the algorithm of the Safety Zone program. Padua score is evaluated in all clinical patients and Caprini score, in case of surgery of intermediate risk for VTE by Safety Zone algorithm, for decision making. Pharmacists intervene in case of non-‐compliance to the protocol. In Intensive Care Units (ICU) and step-‐down unit, VTE risk is evaluated through a daily checklist to assess the adequacy of prophylaxis using a Hospital Management Program, EPIMED Monitor, and recorded by a clinical nurse after validation during a multidisciplinary team round. The compliance is also re-‐evaluated in ICU by the pharmacist at least every 48h. Results: We evaluated 5819 patients between Oct 2012 and Sept 2013 and results of performance markers were the following: 1) Mean proportion of patients with risk assessment within the first 24h in ICU: 95% (89-‐99%); 2) Mean proportion of clinical patients with indication, use and monitoring of therapy, according to institutional protocol: 94% (90-‐98%); 3) Mean proportion of patients with surgery of moderate and high risk who received recommended treatment: 87% (60-‐ 99%); 4) Mean proportion of surgical and clinical patients that used appropriately mechanical methods: 95% (90-‐100%); 5) Incidence of DVT: 0.3% (0-‐0.7%); 6) Incidence of PE: 0.05% (0-‐0.2%); 7) Mortality from VTE: 0.03% (0-‐0.2%); and 8) Hospital readmission within 30 days for VTE: 0.02% (0-‐0.6%). Difficulties related to implementation of pharmacological thromboprophylaxis included fear expressed by surgeons of post-‐operative bleeding, lack of knowledge about the risks of VTE, and disagreement on thromboprophylaxis in surgical patients at intermediate risk of VTE. Regarding alternative measures to pharmacological prophylaxis, the major problems were patients’ resistance to use mechanical methods or refusal to ambulate during hospitalisation. Pharmacists and VTE Commission had a fundamental role disseminating the criteria for correct use of thromboprophylaxis and allowing the institution to reach and maintain good results in VTE prevention. Conclusion: This program allowed implementation of the thromboprophylaxis practice ensuring high compliance rates in medical and surgical patients, thus effectively reducing the VTE rates in hospitals. 2585 Creating A Database For Prevention Of Nosocomial Infection In A Federal Hospital At The City Of Rio De Janeiro Silvio C. Conceição* 1, Eliete L. O. Moura1, Gicélia L. Pereira2, Hercília R. A. Montenegro1, 3 1 Hospital Federal Cardoso Fontes, Ministério da Saúde, 2Universidade Federal do Estado do Rio de Janeiro, Escola de Enfermagem Alfredo Pinto, 3Curso de Graduação em Enfermagem, UNIABEU, Rio de Janeiro, Brazil Objectives: To describe the experience of a team of nurses in the planning , development and implementation of a database to systematise the information of the Committees for Nosocomial Infection Control (CNIC) from a federal hospital in the city of Rio de Janeiro. Methods: This is an experience report whose focus is the description of all stages, from conception of the idea of the database, the construction of the Epi-‐Info 3.5 forms, until the early use by hospital staff. A discussion of the impact of the construction and use of the database in the development of the activities of the professionals the CNIC is performed. The Epi-‐Info is a free tool provided by the Centers for Disease Control and Prevention (CDC), an agency of the United States of America Ministry of Health. Using the Epi-‐Info, it is possible to build structured forms for storage and statistical analysis of data, enabling wide utilisation in health care. The database was structured in three environments: Customer Identification, Diverse Cultures and Cultures of MRSA (Methicillin-‐Resistant Staphylococcus aureus). The study was conducted between the months of November 2011 and February 2012, at the Hospital Federal Cardoso Fontes, Rio de Janeiro, Brazil, and the database is in the validation process. Results: The development work demanded of the study of institutional protocols and scientific articles, which served as the theoretical basis for the study. As this is an innovative idea, the initial operation of the database had great repercussion in the hospital, as it allowed a better classification of the information about the infection. With the systematic use of the database by professionals the CCIH, all positive results of cultures of microorganisms are stored and analysed in a practical way, providing greater knowledge about the details of the framework of infection in the hospital. Statistical tools Epi-‐Info software, coupled with the structure of the database allows storage of susceptibility testing of samples of positive cultures and the analysis of these data can be used to obtain the profile of resistance of microorganisms to antibiotics. As in the first six months of use of database, about five hundred results of cultures of microorganisms have been stored. Conclusion: The present work consisted in a precursor initiative in the use of free software Epi-‐Info 3.5 to develop a database for control of nosocomial infection in a Federal Hospital in Brazil. This information will enable the planning of more effective actions to reduce the rates of nosocomial infection and consequent increase in the safety of clients admitted in the unit. 2592 How To Involve The Professional Tip To Follow Mandatory Safety Practices (ROP): A Successful Report Experience In A Health Care Institution Gilvane Lolato* 1, Anna B. Nunes1, Amanda Alvaro1, Ana C. Figueiredo1 1 Hospital Barra D'or, Rio de Janeiro, Brazil Objectives: To disseminate the mandatory safety practices so that the information gets to the employee at the tip. Patient Safety is no longer an exclusive matter of each institution, but a global issue where information is disseminated among professionals to ensure the improvement of care and patient safety. And for that to happen, a change in the safety culture in health institutions is necessary so that leaders start to listen to what your employees have to say and from that dialogue build future projects together. The scientific question of this study was: how to take the information to and make it part of day to day of health employee? Methods: During five months we apply the Walk around method through the tool we call BOPE da ROP alluded to the round that is made by the Special Police Operations Battalion, where one team walked by departments wearing a shirt with the symbol of BOPE dialogue with employees about mandatory safety practices letting them talk about their routines and signalling where there was mandatory applicability of security practice. This methodology has generated the project titled I Do Safety Care focused on Mandatory Safety Practices that are the Mandatory Practices Required indicated by Canadian Accreditation designed from the speech of employees indicating the mandatory safety practices that the department must adhere to contribute to safety care. While it was happenings the Walk around also every two or three weeks the entire Hospital spoke of two mandatory safety practices in detail containing what it is, who does and how it does. Three tools were created to assist the dissemination of information. One was the Pauta D'or (Agenda) applied in multidisciplinary rounds having as principal physician. The other was called MultiplicaD’Ores (Multipliers) which was first applied by managers at any time of the day that is conducive and from there they identifies employees who would be the multipliers for continuing the process of dissemination of information. And the third strategy adopted was to send text messages to cell phones of employees. To close the project with a golden key we had a Coffee-‐break Time where a video was showed to employees that was produced by their own speech; for those who could answered the crossword words game elaborated from the practices gifts were given. Results: We were able to involve 100% of hospital’s departments and evidenced that 80% of employees were “contaminated” by information. An audit with 50 employees randomly selected from different departments two months after the project had been implemented, showed that 98% had at least heard about the mandatory safety practices. The Coffee-‐break Time had participation of at least 30% of employees. Conclusion: It is concluded that the project was a success because of the presented results showing that the information was disseminated effectively to 100% of hospital departments. As we understand that safety care should be a process of continuous improvement, the question remains: And you, do you do the safety care? References: Security of patient. Available in < http://proqualis.net/seguranca#.VB_xYJRdWSo>. Accessed on January 20Th, 2014. Security of patient. The Quality of Health Services. Available in <http://portal.anvisa.gov.br/wps/portal/anvisa/home>. Accessed on January 20Th, 2014. National Program of Patient Safety. Available in <http://www.paho.org/bra/>. Accessed on January 20Th, 2014. 2188 Correlation Between The Annotation Nursing X Rates Of Nursing Services And Use Of Additional Equipment On Private Hospital Services Renata F. Ganem* 1, Michelle F. Vaz2, Juliana Assi1, Márcia Y. Masukawa1 1 Selection Program Development and Retention of New Nurses, 2Orthopedic Clinic, Hospital Israelita Albert Einstein, São Paulo, Brazil Objectives: To assess the adequacy of annotation nurses in the printed score of single debt. Methods: Quantitative, descriptive, level II in a general private hospital in São Paulo which uses a special form of collecting nursing and use of additional equipment services. Data collection was performed by junior nurses and intern’s graduation from a program of training and development of graduates in the period March-‐October 2013 through an audit form with items related to conform or not conform to the correlation between annotation nursing note and single output (NDU). Descriptive statistics. Results: 144 charts of patients admitted to the medical and surgical clinic were audited. Verified compliance in 56.2% of the nursing notes paediatrics unit, 43.7% in the Paediatric ICU, 50% in Pulmonology, Cardiology 16.6%, 100% in unit pre -‐ admission, 84% in Clinical General Medical, 47. 6% in the Rehabilitation Unit and 100% in Oncology and Haematology compliance compared the recovery of nursing services in paediatrics 31.2% in the Paediatric ICU of 74%, 16.6% pulmonology , cardiology 16, 6% , unit pre -‐ hospital 100 % , 60% general medical clinic , rehabilitation unit, 76.2%, 55.5% oncology and haematology. Conclusion: We found that among eight units audited were adequate correlation between the annotation and note nursing single debt at 100% in unit pre -‐ admission and above 50% compliance was found in general internal medicine, oncology and haematology. The nonconformity between this data correlation was observed in the paediatric ICU with 56.3% in the annotation nursing, cardiology 83.4%, 52.4% in the rehabilitation unit compared to the inadequacy of the release note single debt at 68. 8% in paediatrics, 83.4% in pulmonology and cardiology. The main items in which disagreement occurred this correlation were the items: Application injection , inhalation, phototherapy, diaper changes, and oximetry saturation measurement, dressings use barrier cream, protective folder for ostomy, tissue protective barrier dimethicone Sheild®, soap fluid, urine output monitoring, heparinization of central venous catheter, serum therapy, medication administration, oxygen therapy and blood glucose. The reorientation healthcare professionals should be continuous, promoting collective training and evaluation of performance in order to detect errors and propose improvements over the process faster and more efficient results. The importance of practicing registration procedures and materials records must be informed, avoiding the risk of revenue loss and error recovery, impacting the institution, environment, professional and patient. 2579 Using Trigger Tool To Identify Adverse Drug Events In Cardiology Hospital Mariana L. V. Oliveira* 1, Graziele Silva1 1 Pharmacy, Pró Cardíaco Hospital, Rio de Janeiro, Brazil Objectives: To describe the implementation of the methodology TRIGGER (IHI) for surveillance of adverse drug events in hospitals. Methods: This is a descriptive study on the effectiveness of the Trigger Tool (IHI) in the detection of adverse events related to drug use. Based on the epidemiological profile of the hospital and after discussion with a multidisciplinary group, 9 triggers were selected for monitoring by pharmacist: INR > 6, PTT > 100s, digoxin concentration > 2ng/ml, platelets <50,000, use of antihistamine, vitamin K, flumazenil, naloxone, calcium polystyrene. Results: Between September to December 2013, 54 events were triggered, with 34 (63 %) related to the use of oral antihistamines. However, only 1 case was related to an adverse event. The other 20 analysed triggers were found in the chart, of which 5 (25 %) were related to adverse events: 2 related to the use of coumarin without adequate INR control and 3 to adverse drug reactions. All events were reported to the risk management team. Conclusion: The use of the tool makes possible the tracking of adverse events, contributing to greater vigilance in the use of high risk medicines. After 3 months, according to the epidemiological profile of the hospital, some triggers needed to be changed to increase the ability of detecting adverse events. 1062 The Satisfaction Of Newly Admitted Patients Towards Their Ward Environment Hui-‐Ling Chou* 1 1 Far Eastern Memorial Hospital, New Taipei City, Taiwan Objectives: A survey conducted by the hospital on ward satisfaction levels in 2011 discovered that the mean monthly score for the unit regarding satisfaction with “ward introduction upon admission” ranked at the bottom. There were often times when family members could not locate the water dispenser to fill their kettles or find the rubbish bin to dispose of their rubbish. Methods: Newly admitted patients towards the ward environment introduction was only 55%. This low level of satisfaction was due to a lack of obvious directional signs and route planning, no introduction manual specially designed for the ward environment, a lack of standard operating procedures for introducing the ward environment, and a low rate of implementation by the nursing staff. Proposed measures to rectify the problems include installing directional signs for common destinations and placing them at the entrances and various hallway turns. They should clearly indicate the locations of the rubbish area and water dispenser area, as well as lay out blue and red route signs on the ground to differentiate the locations between new and old buildings. An introduction manual for the ward environment should also be produced and placed inside the table drawer next to patients’ beds for convenience. In addition, a standard operating procedure for introducing the ward should be formulated. Results: The satisfaction of newly admitted patients towards their ward environment rose reached 97%, while the frequency of stray visitors visiting patients not residing in the unit decreased from 52% to 16%. Conclusion: By measures to correct the problems, including installation of signs, a common destination, and put them all turn at the entrance and hallways. Clearly shows the location of the garbage area and water dispenser area and laid the blue and red route signs on the ground, in order to distinguish between the position of the old and new buildings. Brochures ward environment should also be produced and placed in the desk drawer next convenient patient beds. 1082 A Nursing Experience For The Oesophageal Cancer Patient Caring By OREM Theory Yu Chuang Chou * 1 1 Nursing, Far Eastern Memorial Hospital, New Taipei City, Taiwan Objectives: This article describes the nursing experience of a 51-‐year-‐old patient who suffering oesophageal cancer and being hospitalised because of fever and weakness. During January 19 to 28 in 2011, the writer collected the data by observation, pen and paper talk, and body evaluation, assessed the health problems of patient by using Orem self-‐care theory. Methods: Using Orem self-‐care theory. Four major health problems have been found: inactive elimination of the respiratory passages, less than physically needed nutrition, self-‐care deficit and hopelessness. In addition to improving physical discomfort by giving the appropriate measure of caring for the case, provide the training techniques of sputum clearance to implement correctly. The medical team to jointly develop the use of gastrostomy tube feeding care plan and sustained attention training to assist them in getting enough nutrition needs. Supply the follow–up care and support system according to the individual case, show the concern emotion, encourage patient to express his feelings so that patient can participate the treatment actively, reach self–care ability, The author applied a safe, easy, and non-‐invasive complementary therapy program including music therapy, aromatherapy and massage with essential oil to improve the patient's physical and mental states. Results: Through these approaches, the patient learned to release stress, and to express his feelings, so that he could adapt to his current life, changed as it was by the illnesses, and face the impact of those illnesses with a positive attitude and reduce the feeling of hopelessness. Conclusion: We herein address this nursing care experience to provide deeper understanding of the similar cases for all nursing colleagues, thereby enhancing the quality of care in the future. The objective of this case report was to share the nursing experience with clinical nursing staff caring for terminal patients. 1485 A Nurse’s Personal Experience In The Care Of A Chronic Obstructive Pulmonary Disease Patient Yu Fang Huang* 1, Meni Ling Fang1, Mei-‐Hua Sun1 1 Nursing, Far Eastern Memorial Hospital, New Taipei City, Taiwan Objectives: Chronic Obstructive Pulmonary Disease (COPD) is an irreversible disease involving obstruction of air flow in the lungs. In Taiwan, COPD-‐related medical expenditure amount to over $1.3 Billion a year. Due to the nature of the patients and symptoms, qualify of life can be enhanced through continuous assessment to preserve the remaining pulmonary function and maximise independence. The case is a COPD patient suffering from breathing difficulties, weakness of the inspiratory muscles, and low blood-‐oxygen levels. Non-‐invasive positive pressure ventilation treatment had to be used at night when sleeping to improve blood oxygen saturation and reduce the partial pressure of carbon dioxide. As the patient experienced anxiety due to uncertainty of getting off NPPV during the care period. Methods: During the care period running from January 19 through to March 12, 2011, identify the four following care problems in the patient: ineffective breathing pattern (linked to diminished lung expansion limiting oxygen exchange), low
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