High 5s Steering Group Meeting 2008
The three-day Steering Group meeting took place at the Haute Autorité de Santé in Paris, France from 5-7 November 2008.
Participants included policy and decision-makers from the Australian Commission on Safety and Quality of HealthCare; the Canadian Patient Safety Institute; the Agency for Healthcare Research and Quality in the USA; the Ministry of Health Saudi Arabia; the Ministry of Health, Singapore; the Spanish National Quality Agency; the German Coalition for Patient Safety; the Dutch Institute for Healthcare Improvement; the French High Authority for Health, the National Patient Safety Agency of the UK; the WHO Collaborating Centre on Patient Safety designated as the Joint Commission, and WHO staff from the Patient Safety programme.
The Steering Group heard presentations on progress achieved to date regarding development of the Standard Operating Protocols (SOPs), evaluation framework, event analysis plan, a culture of safety tool, and tools from the learning communities and communication subcommittees. Lead Technical Agency (LTA) representatives presented progress on national efforts linked to the High 5s initiative.
Issues that were addressed at the meeting included:
1. Three SOPs finalized and approved by the High 5s Steering Group.
2. Event Analysis: LTAs will determine methodologies for event analysis. An approach to standardize collection of event analysis findings will be finalised.
3. Evaluation Framework: Developed to address harm uniformly for each incident. A hybrid harm scale has been developed based on related work by AHRQ and WHO's International Classification for Patient Safety project.
4. Culture tool: A culture tool developed by AHRQ will be adopted and used by the LTA and participating hospitals. The value of the culture tool will be to help correlate how well an SOP works within the culture of an organization.
5. Learning Communities subcommittee: Responsible for developing a training toolkit and a Wiki-based web-platform for data posting and analysis.
6. Communications subcommittee: Developed the High 5s mission statement and will finalize five fact sheets in early 2009.
7. Translations: Agreements for standardized approaches when translating the SOPs are in place.
8. Resource Plan will address coordination and implementation costs.
country briefs
Australia: Initiated the development of the Communication During Patient Care Handovers SOP
- The Australian Commission on Safety and Quality of Healthcare is addressing the challenges of healthcare-associated infection, patient identification and medication reconciliation issues.
- National work on Communication During Patient Care Handovers will be launched in March 2009 in the Ausie Guide to Clinical Handover.
Canada: Developed the Medication Reconciliation SOP
- The Canadian Patient Safety Institute is implementing projects to address healthcare-associated infection and MRSA, and medication reconciliation.
- The experiences gained from national implementation of the 'medication reconciliation guidelines' will be shared with countries participating in the High 5s initiative.
- Established a High 5s in-country advisory committee, and event analysis group.
Germany
- The German Coalition for Patient Safety has translated the three SOPs into German and has had one national meeting on the High5s.
- Over 20 hospitals interested in participating with the High 5s have been identified and hospital recruitment has been initiated.
The Netherlands
- Dutch Institute for Healthcare Improvement will shortly identify 10 hospitals for implementing the SOPs.
USA: Developed the Correct Site Surgery SOP
- The Agency for Healthcare Research and Quality has been involved in developing the evaluation framework of the SOPs and a culture tool that can be adapted for use in SOP implementation.
- Hospitals interested in implementing the SOPs will be identified in association with a national college of surgeons.
UK: Developed the Concentrated Injectables SOP
- The National Patient Safety Agency has engaged about 14 NHS trusts and recruitment of hospitals is due to commence in February 2009.
- The Agency has developed a toolkit on how to get started in SOP implementation.