he Indianapolis Coalition For Patient Safety The Indianapolis Coalition for Patient Safety It Takes a City Opportunities for Research and Partnership.
Download ReportTranscript he Indianapolis Coalition For Patient Safety The Indianapolis Coalition for Patient Safety It Takes a City Opportunities for Research and Partnership.
he Indianapolis Coalition For Patient Safety The Indianapolis Coalition for Patient Safety It Takes a City Opportunities for Research and Partnership Glenn Bingle, MD, PhD Chair, Indianapolis Coalition for Patient Safety Chief Medical Officer Community Health Network Kathy Rapala, JD, RN, DNP (c) Executive Director, Indianapolis Coalition for Patient Safety Visiting Associate Professor Purdue School of Nursing Objectives • Introduction to the Indianapolis Coalition for Patient Safety • Overview of Coalition interests and projects • Opportunities for research and partnership www.indypatientsafety.org Indianapolis Coalition for Patient Safety Marion County Dept of Health Department of Public Health Deans of Medical RN, Pharm Schools Health Care Excel Health Care Advantage Wishard Veterans Admin Est. 2003 Indiana State Board of Health St. Francis Collaborate for Patient Safety Community Anthem WellPoint IHIE St. Vincent Clarian Eli Lilly Regenstrief Institutes “The Indianapolis Coalition for Patient Safety is a prime example of how collaboration is accelerating change…among very competitive organizations (and) is a national model for community-based process improvement…” --Don Berwick, IHI President and CEO SHARED Vision & Challenge >>Make Indianapolis safest For health care WORKING TOGETHER >> Shared Resources >> Shared Performance Targets >> Shared Accountability >> Shared Funding >> Shared Learning Do not compete on safety! COLLECTIVE ACHIEVEMENT >> Outcomes: Accelerated Improvement USA Safety Collaborative View: Where do we fit? NATIONAL=12 REGIONAL=8 INSTITUTE FOR HEALTH CARE QUALITY IMPROVEMENT JOINT COMMISSION ON HOSPITAL ACREDITATION INSTITUTE FOR SAFE MEDICAL PRACTICE CALIFORNIA (4) ILLINOIS PITTSBURGH WISCONSIN TRI CITY (WASHINGTON STATE) NATIONAL PATIENT SAFETY FOUNDATION Improved Safety INDIANA INDIANAPOLIS et al MINNESSOTA SAN DIEGO STATEWIDE=31 Google Search Maryland Coalition Survey CITY WIDE=2 7 National Collaborators on Safety HCUP Institute for Safe Medication Practices Collaboratives SCIP 100K Campaign AHRQ PSOs Data Sentinel Collection Event Safety Reporting Goals Joint Institute for Healthcare Improvement Commission HCAHPS National Nursing Sensitive Hospital Core Safe National Practices Patient Safety ACE CMS Efforts 8th Scope of Work National Patient Safety Foundation Thoracic Surgery Quality Forum Serious Reportable Events Cancer Care National Ambulatory Quality Leapfrog Alliance Group Rewards Program L Gelinas VHA 07 modified Bingle Safe practices Consumer Partnership for Patient Safety Groups Safe Practices Committee for Quality Assurance Safety Rounds & Survey 2003 2004 Std. Unsafe Abbreviation Std. Surgical Safety site; ID; Time out 2005 2006 Accelerate & Implement All 100K Lives Strategies Std.& Improve Reliability Delivery to Admin of Anticoagulants & Insulin 2007 Std single Plan for Emergency Preparedness/ Avian Flu Response MRSA collaborative With Regenstrief, VA What activities do city & state collaborations engage in? • Professional, public, media education • Standardization and implementation of best practice around safety issues of mutual concern • Coaching; supporting; encouraging best safety practice • Awarding by recognizing excellence • Sharing best practices • Research • Report safety performance • Guideline developing for best practice • Sharing unique resources like simulation labs • Key milestones include: – High Alert Drugs • anticoagulants • Insulin – Surgical Areas – Root Cause Analysis – Patient Safety Rounds – Standardized Abbreviations – Institute for Healthcare Improvement 100,000 Lives Campaign Indianapolis Coalition for Patient Safety Indianapolis Coalition for Patient Safety History • Officially formed in 2003 • 6 Indianapolis healthcare systems— Clarian, Community, St. Francis, St. Vincent, VA and Wishard--decided to collaborate and not compete on the basis of patient safety. • Held an first executive session facilitated by the National Patient Safety Foundation in 2003. Indianapolis Coalition for Patient Safety: Mission & Vision • Improve the safety of patients receiving healthcare in Indianapolis • Make Indianapolis (Indiana) the safest city (state) to receive healthcare in the United States. Initiative Highlights •Anticoagulation •Lilly/Wishard 6 Sigma Collaboration •High Risk IV Standardization Anticoagulation Initiative 2 babies at Methodist die of overdose 4 others also get wrong dosage of anti-clotting drug September 18, 2006 Methodist may speed up safety updates Bar-code system is in place at Clarian North September 20, 2006 Hospital errors to go public in 2007 Indiana identifies 27 mistakes that hospitals will have to report September 21, 2006 Indianapolis Coalition for Patient Safety Recognition – Anticoagulant Workgroup Dan Degnan, PharmD, MS, CPHQ Scott Freeland, PharmD Jim Fuller, PharmD Jim Eskew, RPh, MBA Jen Reddan, PharmD Steve Hultgren, RPh, MBA Leann McGinley-Wright, PharmD Susan Brown, RPh, MBA Bill Malloy, PharmD Chris Scott, PharmD Divya Abraham, PharmD Mechelle Peck, RN Tamra Arnold, PharmD Anticoagulant Workgroup • Goal: Make the use of anticoagulant medications in Indianapolis HealthSystems safer • Partnership identified with the Institute for Safe Medication Practices (ISMP) – Initial model: Collaborative (FMEA, Guided process) – Final model: Best practice (Self assessment, commitment to data sharing and comparison) Anticoagulant Workgroup – Self Assessment Core Safe Practice Challenges • Functional drug interaction warnings for CPOE and pharmacy systems • Medication reconciliation for anticoagulants across the continuum • Majority were “green” across the board Target Safe Practice Challenges • Pharmacy dispensing for all anticoagulant doses • Independent double checks • Clinical pharmacy monitoring services for anticoagulants Anticoagulant Workgroup – Universal Metric Universal Metric Identification • Pre-requisite – Minimize chart review, automated data, meaningful from a safety standpoint, comparable • ISMP and IHI were starting points • Trial and Error Heparin and PTT measures • Protocol (yes or no) • PTT %s in four distinct ranges • Selection rationale – Protocol effectiveness – Electronic data – Sub therapeutic measurement Anticoagulant Workgroup – Library Anticoagulant Workgroup – Computer Script Anticoagulant Workgroup – Computer Script Research wishes • • • • Study of the PTTs Process/computer studies Validation of best practices Process measure refinement Lean Six Sigma Wishard-Lilly Insulin Safety Project Coalition for Patient Safety Executive Leadership Update Objectives • Reaffirm the importance and impact of insulin safety in the hospital setting • Learn how the Lean Six Sigma process and tools were applied to improve the dispensing and administration of insulin at Wishard Health Services • Share project insights obtained by Wishard and Lilly around patient safety • Discuss additional opportunities in the hospital setting Team Members Wishard Health Services Team Lisa Harris, CEO/CMO, Executive Sponsor Divya Abraham, Inpatient pharmacy Kerri DeNucci, Clinical pharmacy Abby Mortier, Inpatient pharmacy Jim Fuller, Pharmacy Director Susan Gallagher, RN Burn Unit Crissy Lough, Quality/Safety Cheryl Young, CNS DM Shirley Howell, NP Hospitalist Tracy Martin, ED Director Lilly Team LeeAnn Blue, VP, Nursing Jim Collins, Exec Director, Devices, Sponsor Bill Malatestinic, Outcomes Research, Sponsor Mark Urban, Director B2B, Key Stakeholder Jana Klopp, Privacy • RFP Doug Whiteman, Outcomes Research • Pre-determined selection criteria Matt Thomas, Packaging Engineer • Targeted opportunity Jay Yamamoto, Black Belt • Mutual Benefit DMAIC Process and Six Sigma Tool Kit Inventory T ech Charter, Mission statement, SIPOC, Risk analysis, High level process map In s u lin a rri ve s at dock In ve n to ry s h ipm e n t U n p a c k a g e in s ulin p la c e in b ins In s u lin s its in re frig u n til p u lle d P la c e b ins in re frig e ra to r R P h ta k e s o rd e r a n d e n te rs in HMM R P h p rin ts o rd e r c h V ia a rg l fo ed r? L a b e l s its u n til p u lle d Y E S : L a b e l p rin ts if via l c h a rg e d fo r Te c h p u lls la b e l D esk T ech Baseline data collection D e c e n tra l: Te c h c h e c k s via ls d a ily in A M a g a ins t c e n s u s fo r D /C p ts D e c e n tra l: Th ro w s aw a y a n y o p e n via ls P la c e s la b e l a n d in s u lin in b a g g ie C D ec en tra en or l tra l? D e c e n tra l: S e t o n c o u n te r o r o n ro u n d C e n tra l: G i ve to R P h to la b e l a n d c h e c k D e c e n tra l: Ta k e s b a g g ie to flo o r no D e c e n tra l: C re d its a n y u n u s e d V ia ls in H M M D e c e n tra l: R e m o ve s la b e ls , re tu rn s to D u n la p re frig e ra to r Analyze G o e s to re frig e ra to r to p u ll a p p ro p ria te in s u lin D e c e n tra l: S o m etim e s g e ts c h e c k e d h e re ? R unner Tech Measure G o p h e r o rd e r fo r in s u lin c om e s in D e c e n tra l: S e ts in “In ”b a s k e t if a lre a d y c h e c k e d D e c e n tra l: R e m o ve s fro m In b a s k e t, p la c es in lo c k e d c a b in e t C he c t c or ked he ck ? ed D e c e n tra l: S e ts ? ? if n o t a lre a d y c h e c k e d D e c e n tra l: S to re d u n til a d m in to p a tie n t C e n tra l: Ta k e s b a g g ie to flo o r S atellite RPh R Ph N O : V ia l N O T c h a rg e d fo r… ? ? ? F loor N urse Define C e n tra l: S e ts in “In ”b a s k e t * C a n s it fo r m in u te s to h o u rs h e re * C e n tra l: S to re d u n til a d m in to p a tie n t C e n tra l: R e m o ve s fro m In b a s k e t, p la c es in lo c k e d c a b in e t Detailed process maps, “Be the vial” hospital tour, Ishikawa fishbone diagram Improve Solution selection, FMEA Control Adherence activities, RACI, Control plan Process Maps In ve n to ry s h ipm e n t U n p a c k a g e in s ulin p la c e in b ins After… In s u lin s its in re frig u n til p u lle d P la c e b ins in re frig e ra to r In s u lin a rri ve s at dock In ve n to ry s h ipm e n t U n p a c k a g e in s ulin p la c e in b ins In s u lin s its in re frig u n til p u lle d P la c e b ins in re frig e ra to r L a b e l s its u n til p u lle d D e c e n tra l: S o m etim e s g e ts c h e c k e d h e re ? D e c e n tra l: Te c h c h e c k s via ls d a ily in A M a g a ins t c e n s u s fo r D /C p ts C D ec en tr a en or l tr a l? D e c e n tra l: S e t o n c o u n te r o r o n ro u n d C e n tra l: G i ve to R P h to la b e l a n d c h e c k D e c e n tra l: Ta k e s b a g g ie to flo o r C e n tra l: Ta k e s b a g g ie to flo o r C D e c e n tra l: Th ro w s aw a y a n y o p e n via ls no D e c e n tra l: C re d its a n y u n u s e d V ia ls in H M M F loor N urse D e c e n tra l: R e m o ve s la b e ls , re tu rn s to D u n la p re frig e ra to r D e c e n tra l: S e ts in “In ”b a s k e t if a lre a d y c h e c k e d D e c e n tra l: R e m o ve s fro m In b a s k e t, p la c es in lo c k e d c a b in e t he c or ked tc he ck ? e d D e c e n tra l: S e ts ? ? if n o t a lre a d y c h e c k e d D e c e n tra l: S to re d u n til a d m in to p a tie n t R P h ta k e s o rd e r a n d e n te rs in HMM R P h p rin ts o rd e r C e n tra l: S e ts in “In ”b a s k e t * C a n s it fo r m in u te s to h o u rs h e re * C e n tra l: S to re d u n til a d m in to p a tie n t C e n tra l: R e m o ve s fro m In b a s k e t, p la c es in lo c k e d c a b in e t Te c h p u lls la b e l D esk T ech P la c e s la b e l a n d in s u lin in b a g g ie R unner Tech D esk T ech R unner Tech G o e s to re frig e ra to r to p u ll a p p ro p ria te in s u lin G o p h e r o rd e r fo r in s u lin c om e s in c h V ia a rg l fo ed r? L a b e l s its u n til p u lle d Y E S : L a b e l p rin ts if via l c h a rg e d fo r G o e s to re frig e ra to r to p u ll a p p ro p ria te in s u lin P la c e s la b e l a n d in s u lin in b a g g ie D e c e n tra l: S o m etim e s g e ts c h e c k e d h e re ? D e c e n tra l: Te c h c h e c k s via ls d a ily in A M a g a ins t c e n s u s fo r D /C p ts C D e c e n tra l: S e t o n c o u n te r o r o n ro u n d C e n tra l: G i ve to R P h to la b e l a n d c h e c k D e c e n tra l: Ta k e s b a g g ie to flo o r no D e c e n tra l: C re d its a n y u n u s e d V ia ls in H M M D e c e n tra l: S e ts in “In ”b a s k e t if a lre a d y c h e c k e d D e c e n tra l: R e m o ve s fro m In b a s k e t, p la c es in lo c k e d c a b in e t he c or ked C e n tra l: Ta k e s b a g g ie to flo o r tc he ck ? e d D e c e n tra l: S e ts ? ? if n o t a lre a d y c h e c k e d D e c e n tra l: S to re d u n til a d m in to p a tie n t Check all meds centrally D ec en tr a en or l tr a l? C D e c e n tra l: Th ro w s aw a y a n y o p e n via ls D e c e n tra l: R e m o ve s la b e ls , re tu rn s to D u n la p re frig e ra to r F loor N urse Y E S : L a b e l p rin ts if via l c h a rg e d fo r Te c h p u lls la b e l R Ph N O : V ia l N O T c h a rg e d fo r… ? ? ? c h V ia a rg l fo ed r? R P h ta k e s o rd e r a n d e n te rs in HMM R P h p rin ts o rd e r S atellite RPh R Ph N O : V ia l N O T c h a rg e d fo r… ? ? ? G o p h e r o rd e r fo r in s u lin c om e s in S atellite RPh In s u lin a rri ve s at dock Inventory T ech Inventory T ech Before… Quick win, eliminates steps checking @ satellites, delays getting meds to floors C e n tra l: S e ts in “In ”b a s k e t * C a n s it fo r m in u te s to h o u rs h e re * C e n tra l: S to re d u n til a d m in to p a tie n t C e n tra l: R e m o ve s fro m In b a s k e t, p la c es in lo c k e d c a b in e t Research wishes • Process and methodology of Six Sigma for safe insulin administration within facilities; eliminate steps/rework • Gaps and opportunities analyzing process maps vs. reality • Standard Operating Procedures re: insulin administration • Standard training for physicians, nurses, techs and pharmacists • Report Card on the progress • Work on other issues identified: meal times/tests/procedures and relation to our patients on insulin therapy SPREAD!!!! Other initiatives • OR time out/site verification standardization • Standardization of high risk infusions (collaboration with Purdue PharmaTAP). • Cardinal grant for IV smart pump comparative data base. • Severe sepsis initiative Opportunities for Partnership • Research opportunities – 6 hospital systems – Suburban Health Organization – Gear toward relevant needs in hospital systems • Process measurement/validation – Observational research – Process improvement • Grants, articles, partnerships…many opportunites How to work with ICPS • Come to a meeting. We meet the last Tuesday every other month. • Chat with either of us regarding specific opportunities • Explore grant opportunties on the subjects we discussed Thank you!