Trans-Atlantic alliance to compare patient safety performance between the UK and US organizations The business case for preventing inpatient falls

Dr. Mahmood Adil – National Health Service , England Diane Huntley - Kaiser Permanente, CA Pascal Briot - Intermountain Healthcare, UT [email protected]

Hospital Engagement Network Falls Affinity Group Call – March 7, 2013

Process and Methods

• • • • Align on definition of fall severity between organizations * Develop methods to track incremental cost of harm that could be standardized and easily used by other global systems Generate effective partnerships between clinical, finance, and analytic experts in three organizations Demonstrate that international collaboration is an effective sharing and learning tool to make a difference in reducing patient harm around the globe

* See Appendix I

Journey of our collaboration

Will May 2010 Idea Sept 2010 Execution Nov-Dec 2010 Outcomes Jan-May 2011 Cost of Falls Calculator 2012 Refining Falls project Starting ADE project 2013 Sept. 2010: Initial Meeting with NHS, Kaiser Permanente, and Intermountain IHI Forum 2011: Poster Presentation International Forum & ISQua 2012: Oral Presentation Upcoming NPS Congress 2013: Oral Presentation

Challenges for All

1. How to identify rate and severity of falls

Impact of information measurement system and professional cultures

2. How to identify savings associated with reduction in rate of falls

Matched cohort comparison of length of stay, labs, imaging and Rx utilization

3. How to track intervention “cost”

Identification of intervention & accounting methodologies

4. How to “put it all together”

Cost of falls calculator B-C=D B enefits(costs of poor quality or service) C osts (costs of improvement intervention) Dividends (Case for Change)

1. Fall prevalence rate per 1000 patient days 2010 data 2,5 2,0 1,95 1,74 2,09 1,5 1,37 1,0 0,72 0,63 0,64 0,5 0,0 N = 873 1969 524 No Injury 0,14 0,03 N = 399 773 285 Minor

Severity of Injury

N = 83 40 29 Moderate NHS KP IH 0,03 0,02 0,07 N = 15 24 4 * Major * IH sample size for major injury not statistically significant

2. Mean extended length of stay 2010 data 25 10 5 20 15 7,3 6,6 4,7 0 N = 873 1,969 524 No Injury 10,2 9,1 8,0 7,4 3,3 1,6 N = 399 773 285 Minor N = 83 40 29 Moderate

Severity of Injury

NHS KP IH 23,0 20,0 6,1 N = 15 24 4* Major * IH sample size for major injury not statistically significant

3. Tracking of interventions Intermountain example

Rate of Falls with Injury per 1000 Patient Days

4,5 4 3,5 3 2,5 2 1,5 1 0,5 0 Injury No Injury

1998

Creation of Patient Safety Team Meeting Prep and Follow-up Nursing Falls Education Develop protocol

Year, Quarter 2005 - 2007

Creation Safe Patient Handling team (earned Magnet status, gait belts & lift system, awareness signs) Standardize Fall definition Added electronic risk scoring/protocol to event system Developed web reports for front line Inclusion of falls on nurse manager dashboard

2010 - 2011

Board Goal (2010) Designated Fall Champions Post Falls Assessment Implementation Mini-RCA for Falls (Falls Assessment Huddle) Patient Safety Index Skill Pass Off for bed types New Bed (with integrated bed alarm) Nurse Call System Integration

3. Tracking of Intervention

Dimensions

Leadership Process improvement Infrastructure Information system & reporting

Intermountain 1998 - 2010

Teams and Champions • Creation of Patient Safety Team (1998) • Creation Safe Patient Handling Team (2005) • Board Goal & Designated Fall Champions (2010) Education & Assessment • Develop Protocol & Nursing Falls Education (1998) • Standardize Fall Definition (2005) • Post Falls Assessment Implementation & Patient Safety Index (2010) Patient Equipment & Staff Awareness • Magnet status, gait belts & lift system, awareness signs (2005) • New Bed (with integrated bed alarm) • Nurse Call System Integration (2010) Electronic Reporting • Added electronic risk scoring /protocol to event system • Developed web reports for front line. Inclusion of falls on nurse manager dashboard (2005)

Kaiser 2007-2010

HEROES (Hospital & Emergency Dept Reliability & Operational Excellence for Safety) • Create reliable clinical practices in all 21 medical centers • Standards of practice & successful practices shared on Monthly Collaborative Calls (2009) Fall Prevention Bundle 2007 • Start-of-shift huddle • Schmid assessment • Purposeful hourly rounding • Toileting assistance • • Alignment with Pharmacy and PT Staff, patient, and family education • Falls Prevention Bundle May 2009 • Vital Behaviors Schmid Plus ABCs Age, Bone, Coagulation, Recent Surgery • Ongoing requirement for nurses to attend yearly training Patient Equipment & Staff Awareness • Specialty low beds • Gait Belts • Chair alarms, bed alarm s • Door signs, yellow armbands • Care board Electronic Reporting • Electronic Responsible Reporting Form • KP Health Connect (Kaiser Permanente electronic medical record)

NHS 2009-2011

• • • • The • Strategic Team Improvement Leader Trust Chief Executive/Senior Sponsor Medical Director Finance Director Dir of Nursing and Clinical Governance • Head of Health Informatics Multi-faceted Fall interventions Checklist (March 2010) • Toilet & Mobility • Environment • Assessment • Medication • • Raising Awareness Education & Training Patient Equipment & Staff Awareness • Low profile beds • New bed rails • Care board Data Intelligence & Review System • Develop and integrate the safety fields in clinical , administrative and financial patient level costing) data electronically • Improve data availability and accessibility to frontline staff • Regular audits to review performance and update protocols

4. Fall risk calculator

Pre-requisite to use the calculator

1. Accurate identification of falls   Robust event system to identify falls and severity.

Culture of safety and no-blame 2. Calculating associated cost due to a fall   Incremental length of stay by using cohort matching methodology Convert incremental resource use into actual cost 3. Track & cost your intervention to reduce fall  Identify intervention in terms of leadership, process improvement, infrastructure, information system and reporting  Estimate the cost of intervention (allocated equipment cost over time) 4. Putting it all together using the calculator

Lessons learned due to our collaboration

1. Accurate and consistent identification of falls   Agreed on use of standard definition of severity of falls and methodology to measure falls rate.

The WHO should include new codes for hospital associated falls in its next version of ICD classification system.

2. Track and cost your intervention to reduce fall  Quality Improvement culture to track intervention: clinical and finance teams need to find ways to share data and work together for creating the ‘business case for safety’ and achieving sustainable outcomes.

 Need a good activity based cost accounting system. If it is not possible to separate out the effect of an intervention and the cost of it because interventions are cumulative, it may be best to look at impact over time.

3. Degree of similarity of interventions across institutions  ‘Extended Length of Stay’ is a good indicator to quantify harm-related incremental cost and resource utilization.

Multidisciplinary Team

Program Office Quality Dept Project Management Northern California Region Sponsors NCAL Quality NCAL Finance Northern California Risk and Safety HEROES Initiative California Analytics Wrightington, Wigan and Leigh Hospital Patient Harm Reduction Program Finance Quality Analytic Institute for Health Care Delivery Research Clinical Program Leadership Finance Analytics Patient Safety Clinical Quality ROI Tactical Team

Intermountain ROI tactical initiatives

• • • Led by our Asst. VP for quality and patient safety and reported to our CNO / VP for clinical operation Mission: –

To build a partnership between clinical and financial experts to use the best available data and expertise

–

To provide careful ROI analysis of quality and patient safety initiatives in order to give leadership insight into strategic opportunities

–

To build a standardized approached to calculating ROI that can be “exported” to other initiatives on a system, regional or facility level

–

To quantify existing quality improvement projects that may assist in meeting Intermountain’s goal of maintaining a low rate of cost increases to CPI+1%

Areas of concentrations: –

Falls

– –

Adverse Drug Events (ADE) Central Line Associated Blood Stream Infection (CLABSI)

Intermountain fall with injury rate

Falls with Injury Intermountain System

2,5 2,0 1,5 1,0 0,5 0,0 2007 2008 Average 2009 2010 Falls with Injury LCL 2011 UCL 2012

Methodology for ROI calculation

Savings: – Decrease payment on legal claims – Decrease variable cost due to • • reduction in complication associated with fall reduction reduction in LOS

Potential impact on revenue stream?

Expenses: – Costs of implementation of falls prevention initiatives • • • Personnel (new staff, education, training, …) IT / information / measurements (Risk event system, data tracking and reporting, …) Infrastructure (equipment, supply, …)

How to allocate capital expenditure?

Decreased Payment on Legal Claims

Reduced Patient Costs

Savings

= 𝑉 𝑐𝑜𝑠𝑡 𝑤/𝑓𝑎𝑙𝑙 − 𝑉 𝑐𝑜𝑠𝑡 𝑤/𝑜𝑢𝑡𝑓𝑎𝑙𝑙 𝐹𝑖𝑥𝑒𝑑 𝑃𝑎𝑦𝑒𝑟𝑠 ∆𝑁𝑂𝐼 = 𝐹𝐹𝑆 𝑃𝑎𝑦𝑒𝑟𝑠 𝑆𝑣𝑛𝑔𝑠 ∙ #𝑅𝑒𝑑𝑢𝑐𝑒𝑑 𝐹𝑎𝑙𝑙𝑠 𝑆𝑣𝑛𝑔𝑠 − 𝑆𝑣𝑛𝑔𝑠 𝑃𝑎𝑦𝑚𝑒𝑛𝑡 𝐶𝑜𝑠𝑡

Approximation of Financial Outcome

Next Steps

1. Refine Patient Cost Reduction Calculations

•

Verify whether charges related to falls are billable

•

Determine appropriate comparison I.

II.

No Falls : Falls No Falls : Falls with Injury

2. Investigate employee injury claims 3. Refine allocation of capital costs

•

Beds, remodeling

•

Across applicable risk events (pressure ulcer,…)

4. Create methodology for budgeting utilization changes at dept. level 5. Apply ROI methodology to other risk events

Lessons learned for a successful international collaboration

1. Clear and simple objective to be agreed from the outset 2. Staged approach to build the momentum and measurable goals for each stage 3. An effective coordinator able to leverage the use of web technology 4. Establish common ground for data sharing and incorporating each others standards in a practical manner 5. Act like one team with commitment and flexibility to achieve common results across the organizations

Questions

Thank you!

Appendix I -Severity of Falls Definitions

Severity Categorization

No harm/injury

National Health Service

Where no harm came to the patient.

Intermountain Healthcare

Absence of harm or injury, with no requirement of care or treatment

Kaiser Permanente Northern California

An event not resulting in no harm or injury coupled with no explicit expression of dissatisfaction by affected member, visitor, or family; a reoccurrence of this event is not likely to result in a serious adverse outcome Low/Minor harm/injury Moderate harm/injury Severe/Major harm/injury 22 Where the fall resulted in harm that required first aid, minor treatment, extra observation or medication.

Where the fall resulted in harm that was likely to require outpatient treatment, admission to hospital, surgery or a longer stay in hospital.

Where permanent harm, such as brain damage or disability, was likely to result from the fall.

Detectable harm or injury. Without treatment, the patient would have fully recovered Detectable harm, injury, or functional impairment lasting for a limited time only. Injury or impairment would not restore itself if untreated

Temporary

Non-treatment would result in the loss of life or permanent loss of function. Patient returns to baseline status without permanent injury

Permanent

Non-treatment would result in the loss of life or permanent/long-term loss of function. Patient does not return to baseline

No Treatment

An event resulting in an injury requiring no treatment, e.g. bruises, scrapes or bumps

With Treatment

An event that required minor intervention (e.g. application of a dressing, ice, cleaning of a wound, limb elevation, topical medication, or x-ray), no loss of function; An event that resulted in an injury requiring physician treatment, such as sutures, splints, casts, minor surgical repair, closed reduction, or prescription for an antidote; An injury, which requires minor intervention to remain temporary; An event that resulted in a permanent injury or one that is life threatening, or requires close monitoring at an increased level of care, or intervention such as major surgery to keep injury from becoming permanent.

23

Appendix II - Schmid Plus ABCS

Appendix III - Collaboration Team

Leaders Quality Improvement Finance/ Analytics Patient Care Services KP Mike Rowe Barbara Crawford Maureen Hanlon Diane Huntley Jason Jones, PhD Sabrina Dahlgren Patricia Kipnis Tom Winn Rebecca Gambetese Nancy Corbett Cecelia Crawford Lorraine Woo Intermountain Pascal Briot Jefrey Huntington Marlyn Conti Eric Crawford Jan Orton Andrew Sorenson Andy Merrill Marlyn Conti Robin Betts NHS Mahmood Adil Andrew Foster Christina Heaton Micky Milohtra Pat O’Brien Keith Griffiths Claire Jacobson Pauline Jones Gill Harris