Transcript Document

Making Indiana the Safest State:
The Challenge and the Opportunity
BETSY LEE, RN, BSN, MSPH
INAHQ SPRING CONFERENCE
M AY 9 , 2 0 1 4
Conflicts of Interest Disclosures
 The speaker has nothing to disclose.
Session Objectives
 Discuss the status of statewide patient safety
improvement in Indiana compared to national
benchmarks
 Evaluate potential impact of the Partnership for
Patients initiative on patient safety at the local level
 Outline leadership strategies for engaging front line
staff in addressing harm across the board
4
To make
Indiana the
safest place
to receive
health care
in the United
States,
if not the
world
Indiana’s Bold Aim
Inaugural Indiana Patient Safety Summit - March 2010
The Challenge: Indiana Performance
 How will we know we are the safest state?
 Challenge to find comparative data for many safety
measures
 No publicly available comparative data for ADE’s,
Falls, Pressure Ulcers, VTE, VAP, birth-related
injuries, early elective deliveries
 Infections: CDC HAI Progress report



Nationally, CLABSI dropped 44% from 2008 to 2012
The reduction in Indiana was only 34%
CLABSI SIR increased from 2011 to 2012
Indiana 2012 Healthcare Acquired Infections
Infection
Comment
Indiana
SIR
Nat’l SIR
CLABSI – 102
hospitals
Indiana’s 2012 state CLABSI SIR is
significantly
worse than the 2012 national SIR.
0.66
0.56
CAUTI – 104
hospitals
Indiana’s 2012 state CAUTI SIR is
similar to the
2012 national SIR.
1.05
1.03
SSI – Colon – 105
hospitals
Indiana’s 2012 state Colon Surgery SSI
SIR is significantly worse than the 2012
national SIR.
1.04
0.80
SSI – Abdominal
Hysterectomy – 98
hospitals
Indiana’s 2012 state Abdominal
Hysterectomy SSI SIR is significantly
better than the 2012 national SIR.
0.52
0.89
Source: National and State Healthcare Acquired Infections: Progress Report
Centers for Disease Control and Prevention, March 2014
http://www.cdc.gov/hai/pdfs/stateplans/factsheets/in.pdf
Sepsis Mortality Reductions are Promising
Indiana Inpatient Septicemia Mortality Rate
18.00%
16.00%
Began sharing
coalition reports
14.00%
12.00%
10.00%
8.00%
6.00%
Statewide
Heart Failure 30 Day Readmission Rate
8
Heart Failure 30 day Readmissions
Rank State Rate
Rank State Rate
1
UT 23.11%
27 TX 24.57%
2
OR 23.38%
28 AL 24.68%
3
HI 23.45%
29 AZ 24.73%
4
CO 23.56%
29
KS 24.73%
5
ID 23.60%
31 MO 24.74%
6
WI 23.63%
32 OH 24.80%
7
DE 23.73%
33 CT 24.81%
8
VT 23.75%
34 VA 24.82%
9
NH 23.79%
35
FL 24.98%
10 MT 23.87%
35 PA 24.98%
11
IA 23.92%
37 OK 25.05%
12 ND 23.98%
38 MA 25.17%
13 NM 24.05%
39 TN 25.20%
14 WA 24.07%
39 NV 25.20%
15
IN 24.09%
41 WV 25.31%
16 ME 24.17%
42
IL 25.37%
17 AK 24.23%
43 LA 25.60%
18 WY 24.30%
44 KY 25.61%
19 NC 24.33%
45
RI 25.77%
20
SC 24.43%
46 MS 25.80%
20 MI 24.43%
47 AR 25.91%
22 GA 24.46%
48 MD 25.99%
23 MN 24.47%
49 NY 26.08%
24 NE 24.50%
50 DC 26.21%
25 SD 24.55%
51
NJ 26.50%
25 CA 24.55%
23.79%
18.91%
23.87%
23.38%
23.60%
24.30%
23.75
%
23.98%
24.47%
23.11%
24.55
%
24.73
%
24.50% %
23.56
%
24.09%
24.73%
24.23
%
24.80
24.74%
%
24.82%
25.61%
25.20%
25.80%
24.33%
24.43%
24.46
24.68 %
%
25.60%
24.98
%
25.77
%
24.81
%
26.50
%
19.67%
25.37%24.09
%%
25.05%25.91
24.57%
26.08%
24.43%
23.92
25.20%
25.17
%
23.63%
24.55%
24.17%
23.73%
25.99
% 26.21
%
23.45
%
Source: Hospital Compare Release manipulated by WhyNotTheBest.org, , Measure Start – End Dates:7/1/08- 6/30/11
Partnership for Patients Aims
• 40% Reduction in Preventable Hospital
Acquired Conditions
–
–
1.8 Million Fewer Injuries
60,000 Lives Saved
• 20% Reduction in 30-Day Readmissions
–
1.6 Million Patients Recover Without Readmission
• Projection: up to $35 Billion dollars will be
saved
Impact of Partnership for Patients
 Large scale funded national initiative
 Aims aligned with Indiana priorities
 Takes statewide and regional
improvement efforts to scale
 Encourages local adaptation with the
discipline of organized effort and
measurement
AHA/HRET Hospital Engagement Network
12
34 states / 1,622 hospitals
Coalition for Care
Partnership for Patients
National HEN Targeted Harm Categories
15
1)
2)
Adverse drug events
Birth-related injuries
a)
3)
4)
5)
6)
7)
8)
9)
10)
Elimination of Early Elective Deliveries
Central line-associated blood stream infections
Catheter-acquired urinary tract infections
Falls with injury
Surgical infections and complications
Venous thromboembolism
Pressure ulcers
Readmissions
Ventilator-associated pneumonia
Additional Priorities
16
 Leadership Systems
 Culture of Safety
 Teamwork and Communications
 Lean Training
 Innovation and Transformation
 Preventing Harm Across the Board
 Health Care Disparities
2014 CMS Topic Expansion
17
Expansion to other topics:
Sepsis
- MRSA
- Acute Renal Failure
- Clostridium difficile
- Procedural Harm
-
How Might We Achieve Our Aim?
18
 Focus on initiatives to improve all eleven




Partnership for Patients topics
Emphasize measurement, data submission and
transparency
Statewide alignment and energy
Engage front-line teams in patient safety efforts
Embrace personal and collective nature of
change
National Content Development
 Change packages for all 10 topic areas are now
available at www.hret-hen.org.
 National HRET conference calls and webinars to
share evidence-based practice solutions
 National CMS calls sharing ideas for change from
hospitals around the country
 Indiana learning opportunities for many topics
HRET HEN Resources
20
http://hret-hen.org/
HRET/HPOE Resources
21
http://hret-hen.org/
Education and Technical Assistance
 Improvement Leader





Fellowship (HRET)
National Collaborative
(HRET HEN Week)
National and Indiana
webinars
Regional “Roadshows”
Indiana Patient Safety
Summits
IHA Annual Meetings
 Lean Six Sigma training
Medication Safety
Essentials courses (MSE
1.0 and advanced course
MSE 2.0) - on-line, ondemand continuing
education
 Readmissions computerized
simulation model
 Communities of practice
 Site visits and coaching
Special Focus: Adverse Drug Events
Significance:
•
•
•
•
•
•
About 1/3 of all hospital adverse events are related to ADEs
LOS is prolonged by 1.7-4.6 days
ADEs affect 1.9 million hospital stays annually
Cost $4.2 billion annually
Responsible for about 100,000 emergent hospitalizations in
older Americans, annually4
2/3 result from just four medication classes:
o
o
Warfarin, insulin, oral hypoglycemics, and oral antiplatelet agents
2/3 result from unintentional overdoses
1. Classen DC et al. Health Aff (Millwood) 2011;30:581–9.
2. Agency for Healthcare Research and Quality, Rockville, MD, 2011 April. HCUP Statistical Brief #109.
3. Classen DC et al. JAMA 997;277:301–6. Bates DW et al. JAMA 1997;277:307–11.
4. Budnitz, DS et al. N Engl J Med 2011:365:2002-12.
ADE Resources
24
http://www.mnhospitals.org/Portals/0/Documents/ptsafety/ade/Medication-Safety-GapAnalysis-Opioid.pdf
http://patientsafetyauthority.org/EducationalTools/PatientSafetyTools/opioids/Documents
/assessment.pdf
Elimination of EED
Policy
25
Scheduling Form
Consent
CMS: Four Calls to Action
 Reduce harm across the board.
It is a call for
hospitals to produce reductions in every type of harm.
 Take a systemic approach.
It is a call to transform the
organization and its practices to eliminate all the causes of harm. “Using
every means at our disposal.”
 Make your safety transparent to all.
It is a call for
hospitals to define themselves by their safety performance; define
themselves to their employees, doctors, patients and the community.
 Make safety personal & compelling.
Make every
incident of harm a personal patient story that propels the institution to higher
levels of performance.
Harm Across the Board (HAB):
Monthly Update
Hospital: ________________ State: ______ Month: _________
27
Eleven regional safety
coalitions
Members agree not to compete
on patient safety
Layered model of regional
coalitions and affinity groups
supports transformation, learning
and spread
Benefits:
• Innovate at the front lines
• Align with state and national
efforts, and standardize when
beneficial
• Builds local and hospitalspecific capacity for
improvement and innovation
• Encourages safety leadership
at all levels across multiple
professions
Why Regional Efforts Are Important
 Focus on improving patient safety and
decreasing harm
 Identify patient safety issues through
data/events
 Transparency
 Share expertise, resources, and tools
 Develop solutions in coalition and
collaborative learning
 We do not compete on patient safety
Regional Patient Safety
Coalitions: Scope and Focus
Not Competing
on Safety
Leadership and Culture
Staff Engagement
Trusting
Relationships
Culture of
Learning
Transparency
Joy in Work, Give
it Meaning, Make it
Personal, Board
Engagement
Patient/Family
Engagement
Safest
State in
the Nation
Skilled workforce –
technical/safety
competencies;
coaching
Patients and
families involved
in improving
care and
reducing harm
Quality
Improvement on
Harm Reduction
The Coalition for Care has joined with 116 Indiana hospitals and health car e
organizations committed to make Indiana the safest state to r eceive care. The
coalition works to engage and inspir e health care professionals to create new
safe cultures and reliable systems of car e to prevent harm to patients.
COALITION FOR CARE
WHAT IS THE VISION?
The Grand Challenge
Make Indiana
the Safest State
in the Nation for
Patient Safety
WHAT ARE THE GOALS?
WHAT IS OUR WORK?
The Few Things That Matter
The Strategic Focus Ar eas
Quality Improvement
on Harm Reduction
WHAT DIFFERENCE
DO WE MAKE?
WHAT ARE THE METRICS?
The Outputs We Measure
The Outcomes and Results
Direct Outcomes:
Better Health
To create high reliability
organizations who
collaborate and engage in
continuous impr ovement
to achieve best in class
outcomes
‣ Decreased Mortality
‣ Increased Health and Functional
Status
‣ Increased Healthy Life Expectancy
‣ Reduced Disease Bur den
Incidence
‣ Reduced Recovery Time
‣ Increased Patient Productivity
Better Care
‣
‣
‣
‣
What would the safest
state be like?
The Indiana Hospital
Association and its
members join together to
collaborate and not
compete on patient safety
‣
‣
‣
‣
Patient and Family
Engagement
To engage patients and
families in all aspects of their
care and seek their input and
inclusion in advisory
capacities thr oughout the
organization
Increased Standardization of Care
Reduced Medical Errors
Decreased Harm
Increased Patient/Family/
Community Education
Increased Patient Satisfaction
Increased Patient Trust
Increased Staff Engagement
and Morale
Increased Mutual Respect
Lower Costs
‣ Reduced (preventable)
Readmissions Resulting in Less
Cost
‣ Reduced Cost for Patients and
the System
‣ Improved Stewardship of
Resources
‣ Increased Employee Retention
Indirect Outcomes
Healthier Communities
Leadership and
Culture
To create an environment
of mutual trust, respect,
and transparency among
organizations, patients,
and communities
© 2013 Indiana Hospital Association
‣ Safe, Effective, Timely, Efficient,
Equitable and Patient-Center ed
Healthcare
‣ Increased Healthy Life
Expectancy
‣ Educated Public (r egarding
health risk factors - smoking,
alcohol, diet, activity)
‣ Reduced Per Capita Healthcar e
Cost
www.ihaconnect.org
Regional Coalition Transparency
ADE
VTE
Pressure
Ulcers
ABC Hospital
General Hospital
2
1
2
1
4
4
4
2
4
4
4
2
3
2
4
4
4
4
5
3
4
2
St. Elsewhere Health System
County Health
Memorial Hospital
Critical Access Hospital
1
4
0
4
4
3
2
4
3
5
2
4
3
4
2
Z
4
4
3
Z
2
5
2
2
4
3
3
Z
4
5
2
4
4
5
4
4
3
3
2
2
4
5
2
4
Hospital Name
EED
OB
Falls
VAP
CAUTI
CLABSI
SSI
Readmi
ssions
Z
Hospital does not provide services related to
this HAC
3
Demonstrating outstanding improvement
0
Not engaged in work related to HAC
4
Demonstrating sustained high performance or a
national benchmark
1
Engaged in work related to HAC, but not
submitting data
5
Potential Mentor Hospital
2
Engaged in work related to HAC and submitting
data
Partnership for Patients
33
Published in February 2013 Issue
of Health Affairs
What the Evidence Shows About
Patient Activation: Better Health
Outcomes and Care Experiences;
Fewer Data on Costs
Patients with Lower Activation
Associated with Higher Costs;
Delivery Systems Should Know Their
Patients’ ‘Scores’
Enhanced Support for Shared
Decision-Making Reduced Costs of
Care
for Patients with Preference-Sensitive
Conditions
Survey Shows That Fewer Than a
Third of Patient-Centered Medical
Home Practices Engage Patients in
Quality Improvement
34
Patient Engagement and Adverse Events
“[T]here was an inverse relationship
between [patient] participation [in their
care] and adverse events . . . [P]atients
with high participation were half as
likely to have at least one adverse
event during the admission. ”
Source: Weingart SN et al., Hospitalized patients’ participation and its impact on
quality of care and patient safety, International Journal for Quality in Health Care
2011; 1-9.
35
Partnership for Patients
36
HSOPS: Agency for Healthcare Research and Quality
37
2007
2008
2009
2010
2011
2012
2013
2012 AHRQ 90th Percentile
2012 AHRQ 75th Percentile
Nonpunitive Response to Errors
Handoffs& Transitions
Staffing
Teamwork Across Units
Frequency of Events Reported
Communication Openness
Feedback & Communication
About Error
Overall Perceptions of Patient
Safety
Management Support for Patient
Safety
Organizational Learning-Continuous Improvement
Supervisor/Manager
Expectations & Actions
Promoting Patient Safety
Teamwork Within Units
Indiana HSOPS Results
Survey of Patient Safety 2007 to 2013
100.0%
90.0%
80.0%
60.0%
70.0%
50.0%
40.0%
20.0%
30.0%
10.0%
0.0%
Key Elements of Enhancing Cultures
 Teamwork and communication
 Leadership engagement in safety
strategies
 High reliability principles
 Eliminating fear
 Effective handovers and transitions
AHRQ Culture of Safety Survey
 Of the 12 dimensions of culture measured in the
Hospital Survey on Patient Safety, Handoffs and
Transitions has the lowest average percent
positive
 Subscale questions measure these perceptions:
Things “fall between the cracks”
 Important information is lost at the change of shifts
 Problems occur with the exchange of information
across hospital units
 Shift changes are problematic for patients

40
What are hand-offs/handovers?
“The process of transferring primary authority
and responsibility for providing clinical care to a
patient from one departing caregiver to one
oncoming caregiver.”
Patterson & Wears, 2010
41
Characteristics of Effective Handovers
 Face-to-face, verbal, and interactive
 Providers come together and stay in a “zone of readiness
and attention” during information sharing


Limit interruptions
Limit initiation of actions
 Not just about information exchange, but some type of
written, structured tool is employed
 Includes time for anticipation and foresight
 Receiver does read-back to verify content
 Good teamwork as foundation
42
Handover Components
 Introduction and brief patient history
 Overview of current situation
 Safety concerns or potential problems
 Plan (what’s next?)
 Anticipation, reflection, and foresight (what might
go wrong?) - provide context
 Questions and verification
43
Example: DRAW
44
 Diagnosis
 Recent Changes
 Anticipated Changes
 What to Watch For
Source: Seton Southwest Hospital, Austin, TX
Evolution
of Culture
Prof. Patrick Hudson, Leiden University, the Netherlands (From Shell E & P)
Managing the Unexpected
(Weick & Sutcliffe)
 “Mindfulness”:

Ability to see the significance of early and weak
signals and to take strong decisive action to
prevent harm
 “Sensemaking”:
o
o
Process of transforming experiences into updated
views of the system by “taking the time to make
sense out of new and changing circumstances”
“Trust is a product of sensemaking.” – J. Morath
Tools for Sensemaking (Weick and Battles)
 Literally “making sense of events”
 Building a systems understanding to eliminate




and mitigate risks to patients
True sensemaking is reactive and proactive
Focus of learning organizations – systematically
increasing reliability
Provides data-driven framework for sensemaking
through tools and joint reflection
Importance of staff engagement and curiosity
Characteristics of Mindfulness in High Reliability
Organizations (Weick & Sutcliffe)
 Preoccupation with failure
 Reluctance to simplify interpretations
 Sensitivity to operations
 Commitment to resilience
 Deference to expertise
Mindfulness (Weick & Sutcliffe)
 “Struggle for alertness”
 Trouble starts small and is signaled by weak
symptoms that are easy to miss
 Small discrepancies can accumulate, enlarge
and have disproportionately large
consequences
Engaging Front-Line Staff in Safety
 Focus on the systems of care and on




redesigning work processes
Must involve “sharp end” caregivers
Education and training alone will not work –
requires increased “mindfulness”
Cultural change requires strong leadership
Must improve reliability through new
approaches
50
Leadership for Results
 Leverage energy and effort at the front line
 Regionalize technical assistance and education
 Align measures to mark progress
 Concentrate on 11 topic areas
 Build capabilities for future challenges
 Focus on patients and families
 Make it personal
Engaging Front Line Teams
The Leadership Challenge
 Model the Way
 Inspire a Shared Vision
 Challenge the Process
 Enable Others to Act
 Encourage the Heart
The Leadership Challenge
Kouzes and Posner, 2002
Contact
54
Betsy Lee, RN, BSN, MSPH
Director, Indiana Patient Safety Center
Indiana Hospital Association
[email protected]
(317) 423-7795