Reliability of patient safety self-assessment practices established by the National Health Surveillance System: a pilot study

Rodrigues, Ranyelle Christian Dias; Souza, Alessandra Anneliese da Silva; Santana, Heiko Thereza; Gama, Zenewton André da Silva

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FREE THEME • Physis 32 (2) • 2022 • https://doi.org/10.1590/S0103-73312022320220 copy

Reliability of patient safety self-assessment practices established by the National Health Surveillance System: a pilot study

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Introduction: The Patient Safety Self-Assessment Practices is a regulatory action to enhance quality of care. However, validation of its information requires attention. This study aimed to analyze reliability of the Patient Safety Self-Assessment Practices. Methods: Pilot study analyzing the reliability of 21 simple indicators and 1 composite of self-assessment to provide a national sample in future studies. Hospitals with intensive unit care beds participated in the study, and data from self-assessment (SA) and revised self-assessment (RSA) by the health surveillance (HS) were compared with on-site inspection (OSI). Analyses included Kappa and intraclass correlation coefficients. Results: Concordance was satisfactory (Kappa ≥ 0.4) in 12 indicators of SA and 18 indicators of RSA compared with OSI. The least reliable indicators were related to infection prevention protocols. Reliability of the adherence level composite indicator improved with HS revision (SA = 0.89 and RSA = 0.94), despite the low concordance of the high compliance classification. Conclusion: RSA was essential to improve reliability of SA. In addition, some indicators and assessment tools of the HS need revision.

Keywords:
Health surveillance; Patient safety; Health regulation and supervision.

Criteria	Self-assessment	Reviewed self-assessment	On-site inspection
Criteria	n	n	n
1. Patient safety center	9	9	9
2. Patient safety plan	8	3	3
3. Number of lavatories in the ICU	9	9	7
4. Availability of alcohol solution	9	9	7
5. Hand hygiene protocol	8	5	3
6. Patient identification protocol	9	5	3
7. Safe surgical protocol	6	4	3
8. Pressure injury prevention protocol	8	3	2
9. Fall prevention protocol	6	4	4
10. Safe medication protocol	7	2	2
11. SSI due to ICVC prevention protocol	8	6	3
12. UTI due to IUC prevention protocol	7	7	4
13. VAP prevention protocol	8	7	2
14. SSI prevention protocol	6	3	0
15. Microbial resistance prevention protocol	5	2	0
16. Pressure injury risk assessment	6	6	4
17. Fall risk assessment	6	6	4
18. Full completion of the SSC	7	7	5
19. Indirect hand hygiene monitoring	5	3	3
20. Regular reporting of HAI	8	7	7
21. Regular notification of DDD of antimicrobials	5	3	3
% Compliance with Patient Safety Practices
High	7	5	1
Not high	3	5	9
	Median	Median	Median
% Compliance with Patient Safety Practices	83.5	54.8	35.8

Criteria	Self-assessment vs. on-site inspection			Revised self-assessment vs. on-site inspection
Criteria	GAI (%)	Kappa	GAI (%)	Kappa
1. Patient safety center	100	1.00	100	1.00
2. Patient safety plan	50	0.19	100	1.00
3. Number of lavatories in the ICU	80	0.41	80	0.41
4. Availability of alcohol solution	80	0.41	80	0.41
5. Hand hygiene protocol	50	0.19	80	0.60
6. Patient identification protocol	40	0.09	80	0.60
7. Safe surgical protocol	70	0.44	90	0.78
8. Pressure injury prevention protocol	40	0.11	90	0.73
9. Fall prevention protocol	80	0.61	100	1.00
10. Safe medication protocol	50	0.19	100	1.00
11. SSI due to ICVC prevention protocol	50	0.19	70	0.44
12. UTI due to IUC prevention protocol	70	0.44	70	0.44
13. VAP prevention protocol	40	0.11	50	0.19
14. SSI prevention protocol	40	-*	70	-*
15. Microbial resistance prevention protocol	50	-*	80	-*
16. Pressure injury risk assessment	80	0.61	80	0.61
17. Fall risk assessment	80	0.61	80	0.61
18. Full completion of the SSC	80	0.60	80	0.60
19. Indirect hand hygiene monitoring	80	0.60	100	1.00
20. Regular reporting of HAI	90	0.73	100	1.00
21. Regular notification of DDD of antimicrobials	70	0.57	70	1.00
Adherence to patient safety practices
High adherence	40	0.10	60	0.20
	ICC		ICC
% Adherence to patient safety practices	0.899		0.941

PHYSIS - Revista de Saúde Coletiva Instituto de Medicina Social Hesio Cordeiro - UERJ, Rua São Francisco Xavier, 524 - sala 6013-E- Maracanã. 20550-013 - Rio de Janeiro - RJ - Brasil, Tel.: (21) 2334-0504 - ramal 268, Web: https://www.ims.uerj.br/publicacoes/physis/ - Rio de Janeiro - RJ - Brazil
E-mail: publicacoes@ims.uerj.br

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[TFN10] Source: elaborated by the author.

Qualitative variables	n
Hospital ownership
Public	5
Private	5
Type of administration
Direct public	3
Indirect public	2
For-profit	4
Non-profit	1
Quality management
Yes	7
No	3
Risk management
Yes	7
No	3
Accreditation seal
Yes	0
No	10
Certified as teaching hospital (MEC/MS)
Yes	3
No	7
Part of the Sentinel Network
Yes	2
No	8
Performs surgical procedures
Yes	10
No	0
Municipality
Caicó	1
Pau dos Ferros	1
Mossoró	2
Natal	6
Size according to number of hospital beds
Small (< 99 beds)	2
Medium (100 - 199 beds)	7
Large (> 200 beds)	1
Quantitative variables	Median / Mean	Interquartile range / Standard seviation
Number of health professionals in the institution	522 / 712.9	1,415 / 494.4
Total number of hospital beds	122 / 134.8	58.3 / 49.3
Number of adult ICU beds	9.5 / 2.0	4.8 / 6.0
Number of pediatric ICU beds	0 / 2.0	5 / 3.5
Number of neonatal ICU beds	0 / 5.5	11.8 / 8.4
Total number of ICU beds	19.5 / 17.7	14.3 / 7.4