Safety Checklists for the Homecare IndustryA New Strategy to Achieve Better Results

Spring 2013 • Lockton Companies

L O C K T O N C O M P A N I E S

LORI A. SEVERSON, ASP, HEMLoss Control Consultant(303) 414-6155lseverson@lockton.com

DR. ROBYN GERSHON Professor, Department of Epidemiology and Biostatistics and Philip R. Lee Institute for Health Policy Studies, at the University of California School of Medicine

A decade after the Institute of Medicine report, “To Err is Human, Building a Safer Health System,” preventable and sometimes fatal patient incidents continue to plague healthcare. Even with significant worker training and the increased use of technology, medical errors and avoidable adverse incidents involving hospitalized patients continue to occur. To address this, numerous

strategies have been developed and implemented, and one, in particular, seems to be gaining in popularity. This is the use of checklists, long a staple in the broad field of safety management and especially advocated by “high reliability organizations,” such as aviation and the nuclear industry. Despite that, their use had not really

taken hold in healthcare until patient safety experts started to envision healthcare as a “high reliability organization.”

Atul Gawande (2009) explained how the “lowly checklist” has helped surgical teams perform better, limit deadly infections in hospitals and simplify complex processes down to easily repeated ones, free of errors. According to Gawande, we continue to have errors and failures in healthcare because “the volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely or reliably. Knowledge has

Reprinted with permission. This article was originally published in the Vol. 12 No. 3 issue of HealthBeat, the Healthcare Practice Specialty’s technical publication. For more information on ASSE’s practice specialities, visit www.asse.org/ps.

Identification of hazards

is the necessary first step

in hazard remediation,

and a checklist is an

easy-to-use tool.

Spring 2013 • Lockton Companies

2

both saved us and burdened us.” He argues that to overcome “failure,” a different strategy is needed, one that builds on the collective experience of the people within the organization. This “different and new strategy” is exemplified by the use of the simple checklist. Checklists are increasingly used to improve safety and quality throughout the hospital healthcare setting, and they are increasingly used in other nonacute care settings.

Within this context, we share two recently developed safety checklists that potentially can help the home care industry eliminate avoidable errors and help improve the quality of services by eliminating or reducing the risks through a hierarchy of safety controls. Because home health aides experience more than double the national rate of workplace injuries for all industries, ranking them among the ten highest reported for overexertion by the Bureau of Labor Statistics (BLS), implementing a safety risk assessment process is imperative (BLS, 1998-2008).

Identification of hazards is the necessary first step in hazard remediation, and a checklist is an easy-to-use tool to address this. Home health workers and their employers have a vested interest in being “safe at home” on the job. By identifying the hazards through

simple checklists, workers will be safer, healthier and more productive, and employers will earn a reputation for high-quality care, which promotes their sustainability and profitability.

It begins with the “on-boarding” or enrollment of new home care patients, also referred to as clients or consumers. An on-boarding (or question and answer) process already existed to define the patient and his/her care plan. Lori Severson reviewed this process from a safety professional perspective and found that while basic risk/hazard assessment questions were sometimes asked, they were generally

-limited to clinical risk factors and placed minimal priority on employee or patient safety. Further, the process of on-boarding was usually conducted by staff with little or no risk management and safety education.

To enhance the safety of both the employee and the patient/client, she developed the “pre-contract” safety checklist for homecare. Her rationale was that it was at this early stage, when new patients/clients are first enrolled into homecare, that hazards could best be defined and controlled through identification and remediation. The checklist’s purpose

7HealthBeat www.asse.org 2013

diation. The checklist’s purpose is to help the homecare employer identify hazards before deploying a homecare employee, allowing for a proactive approach to reduce employee risk of adverse events. It is a tool that a homecare employer can use to augment the existing on-boarding questionnaire (Figure 1).

In a similar vein, with funding provided by the Agency for Healthcare Research and Quality, Robyn Gershon, an occupa-tional health and safety researcher, devel-oped and tested a new photo-illustrated safety checklist to be used in the conduct of visual safety inspections within the homecare patient’s home (Figure 2). The household safety checklist was designed to be used by home healthcare aides, after receiving a brief 1-hour training session. In a feasibility study, which was recently published in the Journal of Patient Safety, Gershon found that homecare aides could competently use the checklist to visu-ally identify common household hazards potentially a threat to patient safety and quality. The 50-item checklist focused on common hazardous conditions that could result in falls, burns and biohazardous and chemical hazard exposure.

To augment the checklist, a household safety fact sheet—with resources for low- or no-cost remediation and contact infor-mation for emergency agencies, 911 crime stoppers, etc. and nonemergency agencies for local vermin control—was also includ-ed. After 1-hour educational sessions, 54 home healthcare aides conducted inspec-tions using the checklist in 116 patient homes. The inspections took approximate-ly 10 to 15 minutes to conduct; however, all of the patients lived in small apartments.

In many cases, the patients and their family members accompanied the aide through the visual inspection pro-cess. Both aides and patients commented on how easy it was to overlook hazards that, as one aide stated, “were right there under my nose all the time.”

From the pilot testing, Gershon found that 85% of households had at least one hazard, 55% of households had three or more hazards and that the majority of haz-ards presented a risk of slip, trip and fall hazards due to floor rugs, cords and clutter. Forty-seven percent of homes had fire hazards due to storage of items near open flames. The hazard identification process was conducted in a positive and supportive manner, thus ensuring the cooperation of patients and their families and enhanc-ing the learning opportunity it provided. Importantly, it helped both patients and aides understand that many,

if not all, of the household hazards presented a risk to workers and patients and that these hazards could negatively impact other members of the household. The majority of the hazards were also easily corrected or controlled, and the majority of families did not object to the suggested changes.

coNcluSioN

Checklists are a simple-to-use and cost-effective first step in hazard identification and control. Their use in home healthcare is especially appealing, given that household hazards result in significant morbidity, mortality and cost, and present special risks to particu-larly vulnerable patients, namely elderly householders. Household hazards also present risks to all homecare workers, including nurses, medical specialists (such as physical therapists) and workers who typically spend the greatest amount of time in the home healthcare house-

Home Health Services Safety Checklist Pre-Contract

Yes No Questions Comments/Concerns & Recommendations

General Employee Safety

In what type of structure or residence does client reside? Single-family home Apartment Condominium Other

Where will parking be?

How will you enter/exit the home? Identify any personal safety concerns. Lack of lighting Other

Are there pets? Cats # ______ Dogs #______ Other ____________ Any history of biting or scratching? Y/N Proof of vaccinations in the last 2 years? Y/N

Has the client, or anyone else (circle which one) who may be residing and/or expected to visit, have any history of: criminal, ___________________________ (name) psychological, _______________________ (name) violent or combative behavior ___________________ (name) Currently or in the past? Y/N That should be considered in the client care plan? Are there visible and excessive alcohol and/or prescription painkillers and/or other mood-altering medications present with this client? Y/N

Or do you have a concern for substance abuse of any kind? Y/N

Are there firearms present in this client’s residence? Y/N

(We have a zero-tolerance policy for violence)

Fire-Life Safety

Is there smoking (tobacco, cigarettes) in the home? Y/N If yes, who?________________ Estimated quantity per day ___________?

Does the home have working smoke detector(s) installed? Y/N If yes, how many? _________ Carbon monoxide detector(s)? How many? _________ Location(s)?________

Are combustible materials (things that burn) kept to a minimum in the home? Y/N If no, describe. (e.g., old papers, magazines, other items)

Is oxygen used or available for use in the home? Y/N If yes, max. qty on site at one time? Where are extra full cylinders stored?________________________ (If yes, smoking should be prohibited)

Is there an operable five-pound dry chemical fire extinguisher available for use in the kitchen? Y/N If yes, where is it stored?___________________________

Figure 1 Home Health Services Safety Checklist Pre-Contract

This is an excerpt from the checklist. Click here to view the complete document.

FIGURE 1 HOME HEALTH SERVICES SAFETY CHECKLIST PRE-CONTRACT

Spring 2013 • Lockton Companies

3

is to help the homecare employer identify hazards before deploying a homecare employee, allowing for a proactive approach to reduce employee risk of adverse events. It is a tool that a homecare employer can use to augment the existing on-boarding questionnaire (Figure 1).

In a similar vein, with funding provided by the Agency for Healthcare Research and Quality, Robyn Gershon, an occupational health and safety researcher, developed and tested a new photo-illustrated safety checklist to be used in the conduct of visual safety inspections within the homecare

patient’s home (Figure 2). The household safety checklist was designed to be used by home healthcare aides, after receiving a brief one-hour training session. In a feasibility study, which was recently published in the Journal of Patient Safety, Gershon found that homecare aides could competently use the checklist to visually identify common household hazards potentially a threat to patient safety and quality. The 50-item checklist focused on common hazardous conditions that could result in falls, burns and biohazardous and chemical hazard exposure.

To augment the checklist, a household safety fact sheet—with resources for low- or no-cost remediation and contact information for emergency agencies, 911 crime stoppers, etc., and nonemergency agencies for local vermin control—was also included. After one-hour educational sessions, 54 home healthcare aides conducted inspections using the checklist in 116 patient homes. The inspections took approximately 10 to 15 minutes to conduct; however, all of the patients lived in small apartments.

In many cases, the patients and their family members accompanied the aide through the visual inspection process. Both aides and patients commented on how easy it was to overlook hazards that, as one aide stated, “were right there under my nose all the time.”

From the pilot testing, Gershon found that 85 percent of households had at least one hazard, 55 percent of households had three or more hazards and that the majority of hazards presented a risk of slip, trip and fall hazards due to floor rugs, cords and clutter. Forty-seven percent of homes had fire hazards due to storage of items near open flames. The hazard identification process was conducted in a positive and supportive manner, thus ensuring the cooperation of patients and their families and enhancing the learning opportunity it provided. Importantly, it helped both patients and aides understand that many, if not all, of the household hazards presented a risk to workers and patients and that these hazards could negatively impact other members of the household. The majority of the hazards were also easily corrected or controlled, and the majority of families did not object to the suggested changes.

hold—the aides. By identifying and then discussing and controlling these common hazards, the necessary reme-diation steps can go forward.

The pre-contract and post-contract safety checklists are designed to help the homecare industry adequately identi-fy and mitigate/eliminate hazards and to educate employ-ees, as well as families, on hazards in the home. It is recommended that homecare employers use these check-lists to help eliminate avoidable safety errors and thereby improve their employee and patient safety programs. As stated by the Institute for Healthcare Improvement (2007), a nonprofit organization dedicated to the improve-ment of patient care, “Patient safety cannot be adequately addressed if employee safety is not addressed.” It is hoped that through the implementation and use of these safety

checklists, the homecare industry will begin to narrow the disparity between patient and employee safety. •

reFereNceS Bureau of Labor Statistics (BLS). (1998-2008).

Incidence rates for nonfatal occupational injuries and illnesses involving days away from work per 10,000 full-time workers by industry and selected events or expo-sures leading to injury or illness. Retrieved July 7, 2010, from http://www.bls.gov/iif/oshcdnew.htm.

Gawande A. (2009). The checklist manifesto: How to get things right. New York: Metropolitan Books Henry Holt & Co.

Gershon, R.R.M. & Magda, L.A. (2012). Safety in the home healthcare sector: Development of a new

household safety checklist. Journal of Patient Safety, 8(2) 1-9.

Institute for Healthcare Improvement. (2007). How to improve. Retrieved from http://www.ihi.org/ihi/topics/Improvement.

Lori Severson, ASP, HEM, is a loss control consultant for Lockton Co. LLC with 20 years’ safety experience. She has worked with companies in numerous industries and has held a variety of environmental health- and safety-related positions, including positions with a medical device manufac-turer and international manufacturers. A healthcare loss control subject matter expert, Severson has extensive knowledge in the field of safe patient handling, where she has presented at the National Safe Patient Handling Conference and ASSE’s annual Professional Development Conference on successful implementation of safe patient handling programs. She holds an M.S. in Safety from the University of Wisconsin-Stout.

Robyn Gershon, DrPH, is a professor, Department of Epidemiology and Biostatistics and Philip R. Lee Institute for Health Policy Studies, at the University of California School of Medicine. She is also a Professor Emerita from Columbia University, the Mailman School of Public Health, having spent more than a decade there as a researcher. Gershon is an interdisci-plinary research scientist working in the field of occupational and environmental health. Prior to her doctoral studies, she served as the director of biological safety at Yale University. She has been researching the health risks associated with home healthcare for more than a decade and has pub-lished numerous articles on the subject. Her most recent work in this area is a large intervention study, funded by HUD, that is targeting household hazards in the elderly community. Gershon holds a doctoral degree in Public Health from the Johns Hopkins University, School of Public Health, where she was on faculty for several years.

8HealthBeat www.asse.org 2013

R. Gershon Household Safety Checklist Code: __________

1

Today’s Date: __________ Did your patient sign the Consent Form: Yes What time did you start the survey? ____________

A. Information on your patient: 1. Age: __________ 2. Gender (M/F): ________

3. Can your patient walk without help (e.g., a person or thing)? Yes No

4. What is your patient’s overall health status (circle): Poor Fair Good Excellent

5. How many people live in the home: _______ Please list them: _________________________________

6. Do you know the medicines (prescription & nonprescription) your patient takes daily? Yes No N/A

7. How does your patient keep track of their medicines now?

“Pre-poured” or placed in a pillbox (see picture)

Medicines lined up

Other method

No method to keep track

8. Does patient keep any medicine in the home that they are no long taking? Yes No

9. Does the patient use a hearing aide? Yes No B. Please check if any of these hazardous conditions or safety risks ARE found in your patient’s home:

10 Poor lighting

13 Mold or fungus

11 Loose or worn-out rugs or carpets

14 Dangerous space heater (uses flammables)

12 Uneven or slippery floors

15 Dangerous electrical cords (easily tripped over, overloaded outlets, damaged cords)

Figure 2 Household Safety Checklist

This is an excerpt from the complete document. Click here to view the complete version.

FIGURE 2 HOUSEHOLD SAFETY CHECKLIST

Spring 2013 • Lockton Companies

www.lockton.com© 2013 Lockton, Inc. All rights reserved. Images © 2013 Thinkstock. All rights reserved.s:\wp\graphics\white paper\severson\2013\severson_safety checklists for the homecare industry.indd:ezt\tde

Conclusion

Checklists are a simple-to-use and cost-effective first step in hazard identification and control. Their use in home healthcare is especially appealing, given that household hazards result in significant morbidity, mortality and cost and present special risks to particularly vulnerable patients, namely elderly householders. Household hazards also present risks to all homecare workers, including nurses, medical specialists (such as physical therapists) and workers who typically spend the greatest amount of time in the home healthcare household—the aides. By identifying and then discussing and controlling these common hazards, the necessary remediation steps can go forward.

The precontract and postcontract safety checklists are designed to help the homecare industry adequately identify and mitigate/eliminate hazards and to educate employees, as well as families, on hazards in the home. It is recommended that homecare employers use these checklists to help eliminate avoidable safety errors and thereby improve their employee and patient safety programs. As stated by the Institute for Healthcare Improvement (2007), a nonprofit organization dedicated to the improvement of patient care, “Patient safety cannot be adequately addressed if employee safety is not addressed.” It is hoped that through the implementation and use of these safety checklists, the homecare industry will begin to narrow the disparity between patient and employee safety.

ReferencesBureau of Labor Statistics (BLS). (1998-2008). Incidence rates for nonfatal occupational injuries and illnesses involving days away from work per 10,000 full-time workers by industry and selected events or exposures leading to injury or illness. Retrieved July 7, 2010, from http://www.bls.gov/iif/oshcdnew.htm.

Gawande A. (2009). The checklist manifesto: How to get things right. New York: Metropolitan Books Henry Holt & Co.

Gershon, R.R.M. & Magda, L.A. (2012). Safety in the home healthcare sector: Development of a new household safety checklist. Journal of Patient Safety, 8(2) 1-9.

Institute for Healthcare Improvement. (2007). How to improve. Retrieved from http://www.ihi.org/ihi/topics/Improvement.

Lori Severson, ASP, HEM, is a loss control consultant for Lockton Companies with 20 years’ safety experience. She has worked with companies in numerous industries and has held a variety of environmental health- and safety-related positions, including positions with a medical device manufacturer and international manufacturers. A healthcare loss control subject matter expert, Severson has extensive knowledge in the field of safe patient handling, where she has presented at the National Safe Patient Handling Conference and ASSE’s annual Professional Development Conference on successful implementation of safe patient handling programs. She holds an M.S. in Safety from the University of Wisconsin-Stout.

Robyn Gershon, DrPH, is a professor, Department of Epidemiology and Biostatistics and Philip R. Lee Institute for Health Policy Studies, at the University of California School of Medicine. She is also a Professor Emerita from Columbia University, the Mailman School of Public Health, having spent more than a decade there as a researcher. Gershon is an interdisciplinary research scientist working in the field of occupational and environmental health. Prior to her doctoral studies, she served as the director of biological safety at Yale University. She has been researching the health risks associated with home healthcare for more than a decade and has published numerous articles on the subject. Her most recent work in this area is a large intervention study, funded by HUD, that is targeting household hazards in the elderly community. Gershon holds a doctoral degree in public health from the Johns Hopkins University, School of Public Health, where she was on faculty for several years.